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PRACTICAL TREATISE 



DISEASES OF WOMEN. 



BY 

T. GAILLABD THOMAS, M. D., 

PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN IN THE COLLEGE OF PHYSICIANS 

AND SURGEONS, NEW YORK ; PHYSICIAN TO BELLEVUE HOSPITAL \ CONSULTING PHYSICIAN TO 

THE STATE WOMAN'S HOSPITAL ; LATE PRESIDENT OF THE NEW YORK OBSTETRICAL 

SOCIETY ; MEMBER OF THE NEW YORK ACADEMY OF MEDICINE ; OF 

THE COUNTY MEDICAL SOCIETY, ETC. ETC. 



WITH TWO HUNDRED AND NINETEEN ILLUSTRATIONS. 





PHILADELPHIA: 

H E K" E T 0. LE 

1868. 




Entered according to Act of Congress, in the year 1868, by 
HENRY C. LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 



PHILADELPHIA. 
COELIXS, PRIKTER, *7U5 JAYXE STREET. 



TO 



JOHN T. METCALFE, M.D., 

PROFESSOR OF CLINICAL MEDICINE IN THE COLLEGE OF PHYSICIANS AND 
SURGEONS, NEW YORK. 



My Dear Doctor — 

In the publication of this treatise I am secure of at least one 
pleasure, that of acknowledging my great indebtedness to you. 
Such an acknowledgment is usually merely a matter of compli- 
ment, but in my case it is more. Your conduct towards me from the 
first moment of our acquaintance has been such, that I find myself 
called upon, in simple justice, to confess that whatever of profes- 
sional success has thus far attended me has been due much less to 
merit on my part, than to a generosity on yours which has known 
no bounds except those which I have been constantly forced to 
prescribe it. But not only has my connection with you yielded 
me many material advantages ; a constant association with you has 
furnished one of the chief pleasures of my life, and the privilege 
of calling you friend has always been to me a source of pride. 

I know that you will sincerely join me in the desire that our 
relations for the future may be as intimate as those of the past, 
and, like them, be undisturbed by any thought or word of reproach. 

Very truly yours, 

T. GAILLApD THOMAS. 



PREFACE. 



This work was undertaken with the conviction that a treatise, 
such as that which the Author has aimed to prepare, was needed 
as a text-book for the American student and a book of reference 
for the busy practitioner. 

No department of medicine has made greater advances within 
the last few years than Gynecology ; yet the record of its pro- 
gress is, for the most part, to be found only in special mono- 
graphs, journals, transactions of societies, &c, which are inac- 
cessible to the mass of the profession in this country. It has, 
therefore, seemed to the author that a volume which should, 
within a limited space, present the latest aspect of the subject in 
a systematic form, could scarcely fail to prove useful, while his 
position for the last thirteen years as a teacher in this depart- 
ment has encouraged him in the hope that his familiarity with 
the needs of the student may, to some extent, have fitted him to 
undertake the task. 

In the preparation of the treatise the Author has, therefore, 
striven to be as concise and practical as possible, and to bring 
the subject up to the level of the most recent improvements. 
Many chapters will, probably, appear very short when the im- 
portance of their subjects is considered; but it has been his 
effort to condense within the narrowest limits all that is of real 
value in reference to the matters treated. In furtherance of 
this view some very rare condition's have been omitted, as. for 
example, Physometra and Hydrometra. 



VI PEEFACE. 

As the speciality of Gynecology is being rapidly separated 
from its sister branch, Obstetrics, this volume has been devoted 
to diseases of the non-pregnant woman ; such affections as' phleg- 
masia dolens, puerperal fever, mammitis, &c, being properly 
referable to the province of the accoucheur. 

The discussion of all unsettled questions has been avoided, the 
writer preferring to s^ate the views which he regards as correct 
rather than to risk confusion by entering upon lengthened argu- 
ments. 

The space allotted to historical sketches may be regarded by 
some readers as unnecessary; yet it has seemed to the Author 
that the information thus conveyed with respect to the progress 
of our art from the earliest times might not be unacceptable to 
the earnest student. At the same time, the Author would dis- 
claim any pretensions to profound research by confessing that he 
has drawn largely upon contemporaneous writers for his facts. He 
has more particularly availed himself of the publications of Drs. 
H. Gr. Wright, of London, John "Watson, of this city, Colombat 
de l'Isere, of France, and of Dr. Francis Adams's Notes to Paulus 
jEgineta. The works of Hippocrates, Paul of iEgina, Aetius, 
and some others have, indeed, been constantly by his side, but 
many which have been referred to have been qiioted through 
modern writers. 

The Author takes much pleasure in acknowledging his in- 
debtedness to Dr. B. F. Dawson, of this city, for material assist- 
ance in preparing the work for the press. 

T. GAILLAED THOMAS, 

No: 86 Fifth Avenue, New York. 

February, 1868. 



CONTENTS, 



CHAPTER I. 

HISTORICAL SKETCH OF UTERINE PATHOLOGY 



PAGE 

33 



CHAPTER II. 

THE ETIOLOGY OF UTERINE DISEASES IN AMERICA 

Want of Air and Exercise 

Excessive Development of the Nervous System 

Improprieties of Dress .... 

Imprudence during Menstruation 

Imprudence after Parturition . 

Prevention of Conception and Induction of Abortion 

Marriage with Existing Uterine Disease 



52 

53 
54 
55 
57 

57 
58 
59 



CHAPTER III. 

DIAGNOSIS OF THE DISEASES OF THE FEMALE GENITAL ORGANS . 62 

Rational Signs op these Diseases . . . . . .63 

Management of Patient during Physical Examination . . 65 

Means of Physical Diagnosis . . . . . .66 

Ansesthesia . . . . . . . .66 

The Vaginal Touch . . . . . . .66 

Conjoined Manipulation, or Bimanual Palpation . . .67 

Abdominal Palpation . . . . . . .69 

The Rectal Touch . . . . . . .69 

Vesico-rectal Exploration . . . . . .70 

The Speculum . . . . . . .70 

The Uterine Sound and Probe . . . . .77 

Tents . . . . . . . . .81 

The Endoscope . . . . . . .85 

The Exploring Needle . . . . . .85 

The Microscope . . . . . . .86 

Auscultation and Percussion . . . . . .86 

Recapitulation of Means for exploring Pelvic Viscera and Tissues . 86 



Vlll 



CONTENTS. 



CHAPTER IV. 



DISEASES OF THE VULVA 



Nokmal Anatomy 
Vulvitis 

Purulent Vulvitis . 

Follicular Vulvitis 

Gangrenous Vulvitis 
Inflammation of the Vulvo-Vaginal Gland . 
Eruptive Diseases of the Vulva 
Phlegmonous Inflammation of the Labia Majora 
Rupture of the Bulbs of the Vestibule 

Pudendal Hemorrhage 

Pudendal Hematocele 
Pudendal Hernia 
Pruritus Vulvae 
coccyodynia 



PAGE 

87 
87 
88 
88 
90 
92 
94 
95 
96 
97 
98 
99 
102 
103 
107 



CHAPTER Y. 

RUPTURE OF THE PERINEUM 



111 



CHAPTER YI. 

VAGINISMUS 



121 



CHAPTER VII. 

VAGINITIS 



Simple Vaginitis 

Specific Vaginitis or Gonorrhoea 

Granular Vaginitis 



126 

128 
130 
133 



CHAPTER VIII 

ATRESIA VAQINiE . 



136 



CHAPTER IX. 



142 



Prolapsus Vaginse .... 


. 142 


Vaginal Hernise .... 


. 146 


Cystocele . . . . . 


. 146 


Rectocele . . . . . 


. 147 


Enterocele ..... 


.147 



CONTENTS. 



IX 



CHAPTER X. 

FISTULA OF THE FEMALE GENITAL ORGANS. 

Urinary Fistula 

Vesico-Vaginal Fistula 

Urethro- Vaginal Fistula 

Vesico-Uterine Fistulas 

Vesico-Utero-Vaginal Fistulas 
Treatment .... 
Cauterization 
Suture .... 

Preparation of the Patient 

Sims's Operation 

Bozeman's Operation . 

Mastin's Operation 

Elytroplasty . 
Closure of the Vagina 
Urinary Fistulas Requiring Special Treatmen' 
Vesico-Uterine Fistulas 
Vesico-Utero-Vaginal Fistulas 
Fistulas with Extensive Destruction of the Base of the Bladder 



151 

151 
152 
152 
152 
153 
165 
165 
165 
165 
166 
174 
177 
179 
179 
181 
181 
182 
183 



CHAPTER XI. 

FECAL FISTULAS 



Entero-Vaginal Fistulas 
Simple Vaginal Fistulas 



. 184 

. 187 
. 187 



CHAPTER XII. 

GENERAL REMARKS UPON INFLAMMATION OF THE UTERUS . 189 

Reasons for the Frequency of Failure in the Treatment of Uterine Diseases . 193 

Inattention to General Management and Hygiene .... 194 



CHAPTER XIII. 

ACUTE ENDOMETRITIS . 



197 



CHAPTER XIV 

ACUTE METRITIS . 



200 



CHAPTER XY. 

CHRONIC CERVICAL ENDOMETRITIS 



. 205 



CONTENTS. 



CHAPTER XVI. 

CHRONIC CERVICAL METRITIS 

Resume of Treatment of Cervical Metritis 

CHAPTER XVII. 

CHRONIC CORPOREAL ENDOMETRITIS . 



PAGE 

. 223 

. 237 



238 



CHAPTER XYIII. 

CHRONIC CORPOREAL METRITIS 



252 



CHAPTER XIX. 



ULCERATION OF THE OS AND CERVIX "UTERI 


. 263 


Varieties of Cervical Ulceration . 


. 264 


The Granular Ulcer ...... 


. 264 


The Follicular Ulcer ...... 


. 271 


The True Inflammatory Ulcer ..... 


. 272 


The Syphilitic Ulcer ...... 


. 273 


The Corroding Ulcer ...... 


. 275 


The Cancerous Ulcer ...... 


. 276 



CHAPTER XX. 

GENERAL CONSIDERATIONS UPON DISPLACEMENTS OF THE UTERUS 278 



CHAPTER XXI. 

ASCENT AND DESCENT OF THE UTERUS 
Ascent of the Uterus . 
Descent or Prolapsus of the Uterus . 

Methods of Replacing the Uterus . 

Methods of Sustaining the Uterus 

Means adapted to Decreasing the Weight of the Uterus 

Means for Strengthening Uterine Support 

Elytrorrhaphy 

Sims's Operation of Elytrorrhaphy 

CHAPTER XXII. 

VERSIONS OF THE UTERUS 

Anteversion ..... 

Means for Reduction 

Means for Retaining the Uterus in Position 

Elytrorrhaphy .... 
Retroversion ..... 

Means for Reduction 

Means for Retention 



285 
285 
286 
291 
291 
292 
293 
297 
298 



303 

303 
307 
308 
309 
310 
314 
315 




CONTENTS. 



XI 



CHAPTER XXIII. 

FLEXIONS OF THE UTERUS 

Anteflexion ...... 

Means for Preventing a Recurrence 

Means of Obviating the Consequences of Flexion 
Retroflexion ...... 

Latekoflexion ....... 



PAGE 

. 320 

. 320 

. 324 

. 327 

. 330 

. 334 



CHAPTER XXIY. 

INVERSION OF THE UTERUS. 

Methods of Replacing the Uterus . ... 

Methods of Checking Hemorrhage, the Uterus being left in Situ. 
Methods of Amputating ..... 



. 336 

. 343 

. 347 

. 348 



CHAPTER XXV. 

PERI-UTERINE CELLULITIS 



. 350 



CHAPTER XXVI 

PELVIC PERITONITIS 



. 3fi4 



CHAPTER XXVII 

PELVIC ABSCESS 



Methods of Operating . 

Means for Causing Closure of the Sac 



. 380 

. 384 
. 385 



Methods of Operating 



CHAPTER XXVIII. 

PELVIC HEMATOCELE 



. 386 

. 397 



C HAPTER XXIX. 

FIBROUS TUMORS OF THE UTERUS 



. 80S 



CHAPTER XXX. 

UTERINE POLYPI 

CHAPTER XXXI 

CANCER OF THE UTERUS 



. 417 



425 



Xll 



CONTEXTS. 



CHAPTER XXXII. 



CANCROID TUMORS OF THE UTERUS . 



Fibroplastic Tumors . 
Recurrent Fibroid Tumors 



PAfiE 

435 

435 
436 



CHAPTER XXXIII. 

EPITHELIOMA, OR EPITHELIAL CANCER OF THE UTERUS 

Ulcerating Epithelioma, or Corroding Ulcer of tbe Uterus 
Vegetating Epithelioma, or Cauliflower Excrescence of the Uterus . 



438 

439 
443 



CHAPTER XXXIV. 

DISEASES RESULTING FROM PREGNANCY 

Uterine Moles ....... 

Cystic Degeneration of the Chorion, or Uterine Hydatids 
Subinvolution of the Uterus ..... 

Superinvolution of the Uterus ..... 

CHAPTER XXXV. 

FUNCTIONAL DISORDERS OF THE UTERUS 



CHAPTER XXX VI 

MENORRHAGIA AND METRORRHAGIA . 



449 

449 
452 
454 
456 



458 



Dysmenorrhoea ...... 


. 458 


Neuralgic Dysmenorrhoea . 


. 459 


Congestive Dysmenorrhoea 


. 462 


Inflammatory Dysmenorrhoea 


. ' 463 


Obstructive Dysmenorrhoea 


. 464 


Membranous Dysmenorrhoea 


.471 


~ 


• 



473 



CHAPTER XXXVII. 

AMENORRHEA 



479 



CHAPTER XXXVIII. 

LEUCORRHffiA. 



487 



CHAPTER XXXIX 

STERILITY. 



493 



CONTENTS. 



Xlll 



CHAPTER XL. 

AMPUTATION OF THE NECK OF THE UTERUS 

Varieties of the operation 

Methods of Performance 

Operation by Bistoury or Scissors 

Operation by the Ecraseur 

Operation by the Gralvano-Caustic 

Operations by Drs. J. Kammerer and Guleke, at the German Dispen 



ary 



PAGE 

499 

501 
501 
501 
502 
502 
504 



CHAPTER XLI. 

DISEASES OF THE OVARIES 



506 



Imperfect Development 


3 




. 509 


Hypertrophy of the Ovaries 






. 513 


Ovarian Apoplexy ... . 






. 515 


Dislocations of the Ovaries 






. 516 


Ovaritis . 






, . 517 


Acute Ovaritis .... 






. 518 


Chronic Ovaritis .... 






. 524 


Ovarian Abscess .... 






. 525 



CHAPTER LXI I 

FLUID OVARIAN TUMORS. 
Hydatid Cysts .... 

Ovarian Cysts 

Tapping through the Abdominal Walls . 

Tapping through the Walls of the Vagina 



528 
528 
529 
546 
547 



CHAPTER XLIII. 

OVARIOTOMY 



5G0 



CHAPTER XLIY. 

OVARIAN TUMORS — CONTINUED 

Tumors of the Broad Ligaments 

Solid Tumors of the Ovary .... 



5^9 

589 
595 



CHAPTER XLV. 

DISEASES OF THE FALLOPIAN TUBES 



00 1) 



LIST OF ILLUSTRATIONS. 



FIG. 
1. 

2. 
3. 
4. 
5. 



9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 

30. 
31. 



Ancient valvular specula (Scultetus) . 

Practice of conjoined manipulation (Sims) 

Fergusson's speculum . 

Thomas's telescopic speculum 

Short cylindrical speculum 

Sims's speculum 

Sims's depressor 

Emmet's speculum 

Thomas's modification of Sims's speculum 

Sims's speculum with fixed depressor . 

Cusco's speculum modified 

Nurse holding Sims's speculum (Sims) 

Position for introduction (Sims) 

> Sounds of Valleix and Kiwisch 



Sounds of Simpson and Sims compared (Sims) 

Sims's probe, smallest size 

A sponge tent ..... 

A sea-tangle tent .... 

Tenaculum for fixing the uterus 

Introduction of a tent (Sims) 

Follicular vulvitis (Huguier) . 

Phlegmonous inflammation of the labia majora (Boivin and Duges) 

Plexus of veins of the vestibule (Kobelt) 

Sketch of the anatomical relations of the coccyx 

Normal perineum .... 

Ruptured perineum .... 

Baker Brown's operation for rupture of the perineum, showing the 

denuded surfaces (Brown) 
The same, showing the wound closed (Brown) 
Sims's vaginal dilator .... 



PAGE 

38 
68 
70 
71 

72 
73 
73 

74 
74 
75 
75 
76 
76 

77 

79 

80 

82 

83 

S4 

84 

91 

97 

98 

109 

112 

112 

117 
118 

124 



XVI 



LIST OF ILLUSTRATIONS, 



FIR. 

32. 
33. 
34. 

35. 
36. 
37. 
38. 
39. 
40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 

QQ. 
67. 

68. 
69. 
70. 
71. 

72. 
73. 



Filiform papillae of the vagina (Kilian) 

Epithelium in all stages of development, in simple vaginitis (T. Smith) 

Hard rubber tube with piston, for placing medicated cotton or sup 

positories in the vagina 
Abdominal supporters (Brown) 
Varieties of vesical fistulse 
Long-handled scissors . 
Bistoury for paring edges of fistula 
Paring the edges (Wieland and Dubrisay) 
Diagram showing bevelling of edges 

Sims's sponge-holder with handle nine inches long (Sims) 
Needle held in forceps .... 
Course of the needle .... 
Passing the needle (Wieland and Dubrisay) . 
Forceps for drawing needle 

Twisting the sutures .... 
Fulcrum for supporting wire while it is twisted 
Fork with blunt points to aid the passage of sutures 
Hook for engaging needle . . . 

Sutures twisted (Wieland and Dubrisay) 
Sims's sigmoid catheter 
Removal of the sutures (Sims) 
Bozeman's suture adjuster 
Sutures adjusted 
Button being passed 
Passing the shot 
Stohlmann's hollow neeedle 

Mastin's operation for fistulse of the female genital org 
Wound closed .... 
Coghill's twister employed in the operation 
Example of a case requiring obliteration of vagina (Sims) 
Obliteration of the vagina (Wieland and Dubrisay) 
Vesico-uterine fistulse, showing the cervix slit and the sutures passed 
Anterior lip of fistula united to anterior lip of cervix 
Anterior lip of fistula united to posterior lip of cervix (Wieland and 

Dubrisay) 
Examination for fecal fistulse (Wieland and Dubrisay) 
Inflammation of the uterus, showing the dividing line between body 

and cervix 
Chronic cervical endometritis 
Dr. Quain's representation of the cavities of body and cervix (Quain) 
Dr. Bennet's representation of uterine and cervical cavities (Bennet) 
One of the four longitudinal columns of rugse from the virgin cervix 

(T. Smith) ........ 

Villi of canal of the cervix uteri, covered by cylindrical epithelium 

and containing looped bloodvessels (T. Smith) 
Rod eight or nine inches long, wrapped with cotton 



PAGE 

127 
129 

135 
149 
152 
167 
167 
168 
168 
168 
169 
169 
169 
169 
170 
170 
170 
170 
171 
172 
173 
175 
176 
176 
176 
177 
178 
178 
178 
179 
180 
181 
182 

182 
185 

192 

206 
207 
207 

208 

208 
215 



LIST OF ILLUSTRATIONS 



XV11 



74. 

75. 

7G. 

77. 

78. 

79. 

80. 

81. 

82. 

83. 

84. 

85. 

86. 

87. 

88. 

89. 

90. 

91. 

92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 
100. 
101. 

102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 
117. 
118. 



Syringe for cleansing tlie cervix and vagina . 

Silver probe with slide .... 

Same instrument with cotton wrapped around it and 

Budd's elastic probe .... 

Lente's silver caustic probe 

Lente's cup for fusing nitrate of silver 

Cervical metritis .... 

Buttles's spear-pointed scarificator 

Hard rubber cylinder for dry cupping the cervix uteri 

Davidson's syringe .... 

Tub for vaginal irrigation .^ 

Scanzoni's irrigator .... 

Vaginal suppository tube 

y Cauterizing irons .... 

Cervix blistered by the warm iron in four spots 
Sims's caustic bolder .... 
Corporeal endometritis 
Lente's ointment syringe 

Corporeal metritis .... 

Abdominal supporter of jean or silk 
Abdominal supporter in which the pad covers the hy 
Operation for eversion of cervix 
Sims's tampon placer .... 
Diagram representing the three degrees of prolapsus 
Prolapsus in the third degree (Boivin and Duges) 
Uterine mouth everted, bladder pulled down 
stretched in both vesico and recto-vaginal cul-de-sacs 

}™™ • • • 

Zwanck's pessary 



thread attache 



Zwanck's pessary of box-wood 

Coxeter's modification of Zwanck's pessary 

Roser's pessary .... 

Scanzoni's pessary 

Hoffman's pessary shaped like the pelvis 

Bourjeaud's pessary 

G-ariel's pessary 

Sound with sharp points (Sims) 

Uterus fixed by the sound (Sims) 

Speculum and sound in position (Sims) 

Sims's operation of elytrorrhaphy,- sutures in place 

Emmet's operation of elytrorrhaphy . 

2 



ogastrium 



and 



peritoneum 
(Cruveilhier) 



PAGE 

216 
218 
218 
219 
220 
220 
223 
228 
228 
229 
230 
230 
231 

233 

234 

235 
238 
249 
252 
258 
258 
269 
270 
286 
2S7 

290 

295 

295 

295 
296 
296 
296 
296 
297 
297 
298 
299 
299 
300 
300 



XV111 



LIST OF ILLTSTEATIONS, 



FIG. 

119. Normal position of uterus (Wieland and Dubrisay) . 

120. Position of the pregnant uterus 

121. The degrees of anteversion .... 

122. Gariel's air pessary in place (Wieland and Dubrisay) 

123. Operation for shortening anterior vaginal wall (Sims) 

124. Retroversion of the uterus 

125. The degrees of retroversion 

126. Sims's uterine repositor 

127. Replacing a retroverted uterus (Sims) 

128. Uterus bound down by false membrane (Picard) 

129. Hodge's closed lever pessary . 

130. Hodge's open lever pessary 

131. Scattergood's pessary, with spiral springs in branche 

132. Sims's block-tin pessary 

133. Cutter's pessary .... 

134. Meigs's ring pessary .... 

135. Anteflexion (Wieland and Dubrisay) 

136. Peaslee's stem pessary 

137. Detschy's stem pessary (Wieland and Dubrisay) 

138. Creation of new uterine axis . 

139. Sims's knife ..... 

140. Posterior section of the cervix (Sims) 

141. The uterus descending changes its axis 

142. Scattergood's pessary in position (Peaslee) 

143. Partial inversion of the uterus 

144. Complete inversion (Horteloup) 

145. Uterus inverted by a fibroid attached to fundus (McClintock) 

146. Polypus ..... 

147. Inversion ..... 

148. Sessile fibroid ..... 

149. Partial inversion .... 

150. Reducing an inverted uterus (Sims) . 

151. Plug for making counter-pressure in inversion 

152. Pelvic peritonitis, showing roof of pelvis 

153. Subperitoneal hematocele (Simpson) . 

154. Peritoneal hematocele . . - . 

155. Submucous fibroid (Sims) 

156. Subserous fibroids (Boivin and Dugf-s) 

157. Interstitial fibroid .... 

158. Submucous fibroid (Sims) 

159. Aveling's polyptome .... 

160. Nelaton's forceps (Wieland and Dubrisay) . 

161. The ecraseur, straight and curved 

162. The arms of Sims's porte-chaine (Sims) 

163. Sims's porte-chaine ready for encircling a tumor (Sim 

164. Ecraseur with joints and elastic arms 

165. Gooch's canula armed with a ligature 



s) 



LIST OF ILLUSTEATIOXS, 



XIX 



FIG. 

166. 
161. 
168. 
169. 
170. 
171. 
172. 
173. 
174. 
175. 
176. 
177. 
178. 
179. 
180. 
181. 
182. 
183. 
184. 
185. 
186. 
1S7. 
188. 
189. 
190. 
191. 
192. 
193. 
194. 
195. 
196. 
197. 
198. 
199. 
200. 
201. 
202. 
203. 
204. 
205. 
206. 
207. 
208. 
209. 
210. 
211. 
212. 



A tumor encircled by Gooch's canula . ... 

The ecraseur at work ..... 

Submucous fibroid (Wieland and Dubrisay) . 

A cellular polypus with long pedicle (Boivin and Duges) 

A cellular polypus attached within the cervix uteri . 

Glandular polypi (Boivin and Duges) 

Fibrous polypus growing from fundus (Clarke) 

Fibrous polypus growing from lip of cervix (Sims) . 

Cancer of the body of the uterus 

Scirrhus of anterior lip not ulcerated (Boivin and Duges) 

Cancer in ulcerative stage (Boivin and Duges) 

Cancer in extreme degree of ulceration (Boivin and Duges) 

Transverse section of a vegetating epithelioma (Virchow) 

Vegetating epithelioma (Simpson) 

Cystic degeneration of chorion (Boivin. and Duges) . 

Flexion productive of dysmenorrhea . 

Sounds of hard rubber or metal for dilating the cervix 

Priestly's dilator for the cervix 

Simpson's hysterotome . . . . 

Stohlman's hysterotome .... 

Cervical hysterotomy (Sims) .... 

White's hysterotome ..... 

Dysmenorrhoeal membrane (Simpson) 

Recamier's curette ..... 

Sims's curette, representing the angles at which it may be bent 

Syringe for dry cupping the cervix 

Galvanic pessary ..... 

Vaginal leucorrhoea under the microscope (Smith) . 

Cervical leucorrhoea under the microscope (Smith) . 

Conoid cervix (Sims) ..... 

Flexion a cause of sterility .... 

Version a cause of sterility .... 

Excess of tissue in the cervix (Sims) . 

Covering stump of cervix with mucous membrane (Sims) 

Uterine scissors, bent nearly at a right angle . 

Galvano-caustic apparatus .... 

Side view of the galvano-caustic apparatus 

Trocar for tapping in ovarian dropsy . 

Canula, with India-rubber tube attached 

Scanzoni's trocar and canula .... 

Maisonneuve's trocar and permanent canula (Wieland and Dubrisay) 
Bourjeaud's elastic compressor (Wieland and Dubrisay) 
Ovariotomy, position of operator (Simpson) .... 
Spencer Wells's trocar and canula ..... 
Spencer Wells's clamp ....... 



PAGE 
410 

410 
413 
419 

420 
420 
421 
421 
427 
428 
431 
432 
445 
446 
452 
465 
467 
468 
468 
469 
469 
470 
472 
478 
478 
485 
4S6 
489 
490 
495 
495 
495 
497 
501 
502 
503 
503 
546 
546 

551 

551 
558 
573 

577 



XX 



LIST OF ILLUSTRATIONS 



;:} 



Koeberle's constrictor 



FIG. 

213. 

214. 

215. Storer's clamp shield ..... 

216. Closure of the abdominal wound (Wieland and Dubrisay) 

217. Tubal dropsy (Hooper) .... 

218. Tubal dropsy (Boivin and Duges) 

219. Tubal dropsy (Simpson) .... 



579 

580 
583 
590 
607 
608 



THE 



DISEASES OF WOMEN 



CHAPTBE I. 



HISTORICAL SKETCH OF UTERINE PATHOLOGY. 

Nothing adds more to the interest of the student who investi- 
gates the present condition of any department of science. than a 
knowledge of what was done in reference to it, and what was 
known concerning it in previous ages. This alone would be suf- 
ficient to call for the present chapter in advance of others of a 
more practical character. Any attempt, however, at a full and 
complete review of this subject would be out of keeping with the 
plan of this work. 

That a knowledge of medicine as a science was possessed by 
the ancient Egyptians there can be no doubt, since Plinj^ informs 
us that in the time of the Ptolemies a medical school was estab- 
lished at Alexandria, and dissections of the human body com- 
manded. As to the extent of their acquaintance with it, however, 
we have no information, as the literature of that remarkable 
people has been entirely closed to us, until, within a few years 
past, the genius of Champollion has discovered a key for its com- 
prehension. 

Thus far the deciphering of papyri and tablets has failed to 
enlighten us as to any knowledge which they possessed in Gyne- 
cology ; though we may reasonably hope for such a result in the 
future, as Herodotus 1 distinctly announces the fact of specialties 
existing among them. "Here," says he, "each physician applies 
himself to one disease only, and not more. All places abound in 

» Book II. c. 84. 



34 HISTORICAL SKETCH 

physicians; some for the eyes, others for the head, others for the 
teeth, others for the parts about the belly, and others for internal 
diseases." 

From Hebraic literature, which is so abundantly at our com- 
mand, we learn almost as little upon our subject ; and from the 
time of Moses, about 1500 B. C, to that of Hippocrates, 400 B. C, 
all testimony of knowledge upon it is utterly wanting. And yet 
the learning which the latter evinces in reference to it was surely 
handed down to him from previous ages, for the Greeks were 
instructed by the Egyptians, as the Bomans subsequently were 
by the Greeks. 

TTith the writings of Hippocrates commences the literature 
of Gynecology. He devoted to it three volumes, in which he 
discusses metritis, induration, menstrual disorders, displacements, 
&c. Aretaeus, Galen, Archigenes, and Celsus, who probably 
lived in the first and second centuries, all treated of the sub- 
ject; the first describing accurately the vaginal touch, the varie- 
ties of leucorrhcea, and ulceration of the womb ; while the second 
makes the first allusion on record to the speculum vaginae, as 
being a distinct instrument from the speculum ani, and the third 
gives an excellent description of peri-uterine cellulitis. 

From this time, for centuries, there is abundant evidence that 
the study of the subject was pursued with vigor, but so many of 
the works of the authors of those periods exist only in fragments, 
and so many are strongly suspected of being fictitious, that we 
pass them over to stop at the faithful compilation of Aetius, 1 who 
flourished at Alexandria in the sixth century after Christ. His 
works, compiled in the great library at Alexandria, contain a 
digest of what was known and done by his predecessors and con- 
temporaries, and offer the fullest and most reliable evidence con- 
cerning the knowledge of those times. In quoting him, and his 
immediate successor, Faulus .zEgineta, who was also a compiler, 
though a far less conscientious one, I must be understood as re- 
cording, not the views of these individuals, but those entertained 
by physicians who lived from the time of Hippocrates to theirs, a 
period of about one thousand years. 

I 

1 I am indebted to the library of the N. Y. Hospital for an opportunity of fully 
consulting this and other rare works which were accumulated by the late Dr. 
John Watson. 



OF UTEEINE PATHOLOGY. 35 

In his XVI. book Aetius treats of the diseases of women in such 
a manner as to leave no doubt as to his having had a thorough 
knowledge of many disorders and means of investigation and 
treatment, which being rediscovered thirteen hundred years after- 
wards, have, in many instances, been regarded by us as entirely 
new. Thus he speaks of the speculum, sponge-tents, peri-uterine 
cellulitis, medicated pessaries, vaginal injections, caustics for 
ulcers of the cervix, dilatation of the constricted cervix, a sound 
for replacing the uterus, &c. 

As I have already stated, Galen speaks of the speculum vaginas 
in the second century ; but Aetius still more clearly mentions it 
and gives rules for its introduction, which are copied almost ver- 
batim by Paulus without acknowledgment. 1 The use of sponge 
tents he very fully describes, telling of their mode of preparation, 
and even advising that a thread should be passed through them, 
for removal, and that a succession should be employed till com- 
plete dilatation is accomplished. The importance of injections, 
the douche, hip-baths, and application of caustics to ulcers of the 
cervix, he also dwells upon, and advises the dilatation of a con- 
stricted cervix by means of a tin tube. The variety of vaginal 
injections in use among the Greeks was as great as that of to-day. 
As astringents, pomegranate rind, galls, plantain, rose oil, alum, 
sumach, &c, were employed, and as emollients, linseed, poppies, 
barley, &c, exactly as we use them now. Upon the use of medi- 
cated pessaries they relied to a great extent in the cure of ulcera- 
tions and inflammatory engorgements, employing wool covered 
with wax, or butter mixed with saffron, verdigris, litharge, &c. 
Octavius Horatianus even goes so far as to advise a mixture of 
arsenic, quicklime, and sandarach in very foul ulcers. In addition 
to injections and pessaries, Aetius mentions the use of vapor, 
medicated or simple, conducted up to the cervix by means of a 
reed passed up the vagina. 

The use of a uterine sound, passed into the uterus and employed 
as a repositor, is likewise alluded to by this author, in a passage 
where he advises that displacements of the 'uterus should be cor- 
rected specillo et digito. 

Paul of JEgina, who succeeded Aetius, alludes distinctly to the 

• Dr. H. G. Wright, Med.-Chir. Rev., No. lxxi. 



36 HISTOEICAL SKETCH 

speculum as to an instrument in general use before his time. "If, 
therefore." says he, "the ulceration be within reach, it is detected 
by the dioptra ; but if deep-seated, by the discharges." And 
again: "The person using the speculum should measure with a 
probe the depth of the woman's vagina, lest, the tube of the 
speculum being too long, it should happen that the uterus be 
pressed upon." 

It is curious to see how, even in many minor matters, the 
ancients anticipated discoveries which our contemporaries have 
brought forward as entirely new. For example, the air-pessary, 
made so popular in France and other countries by Gariel, is 
described and recommended -by the Greeks. Colombat 1 declares 
that "the ancient Greek physicians made use of pessaries like 
those just mentioned (air-pessaries), of the form and length of the 
male organ, which is the reason why they are called TtpiaTticxata, 
or priapiform pessaries." Albucasis, in 1101, advised the use of 
an inflated pig's-blaclder for the same purpose. The last-named 
author also describes herpes uterinus, and uterine haemorrhoids 
are alluded to by Paulus JEgineta 2 in this explicit manner: 
"Haemorrhoids form about the mouth and neck of the uterus, 
which will be discovered by the spec alum." And thus it is with 
so many other modern suggestions, that the student of ancient 
medical literature is most willing to admit the truth of the propo- 
sition, formulated by Aristotle over two thousand years ago, that 
"probably all art and all wisdom have often been already fully 
explored and again quite forgotten." 

The learning of the Greek School was appropriated by the 
Eoman, which was an offshoot from it, as the writings of Celsus, 
Aspasia, Moschion, and Antyllus abundantly testify. But the 
knowledge of the schools of "Greece and Rome was destined to 
be scattered abroad. At the period of the subjugation of Egypt 
and the destruction of the celebrated library at Alexandria by 
the Saracens, A.D. 640, it passed as a trophy of war into the 
hands of the Moslem invaders. "In a few centuries the fanatics 
of Mohammed had altogether changed their appearance," says 
the learned Draper. 3 " When the Arabs conquered Egypt, their 

1 Diseases of Females, Meigs' translation, p. 152. 
* Sydenham Society's edition, vol. i. p. 645. 
3 Intellectual Development of Europe, p. 285. 



OF UTEEINE PATHOLOGY. 37 

conduct was that of bigoted fanatics ; it justified the accusation 
made by some against them, that they burned the Alexandrian 
library for the purpose of heating the baths. But scarcely were 
they settled in their new dominion, when they exhibited an ex- 
traordinary change. At once they became lovers and zealous 
cultivators of learning." The physicians of Alexandria were 
greeted by them as instructors, and from the seed thus planted 
sprang up the Arabian School. With other information, of 
course, they gained that pertaining to Gynecology, but, the Ma- 
li omedan laws forbidding the examination of women by one of the 
opposite sex, the study languished in their hands ; and although 
Ehazes, Avicenna, and their successors copied from Greek writers 
upon it, a want of zeal, due to want of personal observation and 
experience, allowed a retrograde movement to occur which left 
the subject enveloped in darkness for centuries afterwards. Al- 
bucasis, one of the last of this school, nourished at the end of 
the eleventh century, and after him, although from time to time 
writers of greater or less merit appeared on diseases peculiar to 
women, nothing worthy of special note occurs, except the occa- 
sional allusion to the speculum, which had evidently fallen almost 
entirely into disuse. 

Although these facts prove that the physicians who flourished 
from the foundation of the Greek School of Medicine, 400 years 
before Christ, to the dispersion of the Alexandrian School by 
the Saracens, 640 years after Christ, were well informed in Gyne- 
cology, and were familiar with means of investigation which 
were subsequently lost or ceased to be appreciated, it must by 
no means be supposed that their knowledge was of the same 
exact and scientific nature as that which has prevailed since the 
modern introduction of the speculum. They did not sufficiently 
separate inflammations of the pregnant and non-pregnant uterus, 
confounded affections of that organ with those of the pelvic 
areolar tissue, and made no distinctions between mucous and 
parenchymatous metritis and morbid states of the neck and body. 
Among their remedies were numerous articles which to-day we 
regard as inert or even injurious — as pigeon's dung, woman's 
milk, stag's marrow, &c. ; and Aetius and Paulus seem to have 
been as partial to the "grease of geese" as our Milesian popu- 
lation is at present. 



38 



HISTORICAL SKETCH 



The learning of the Arabians was in time, as that of the rest 
of the world, gradually enshrouded by the ignorance and super- 
stition of the period termed the "Dark Ages." During that time 
many of their writings, like those of the Greek and Eoman 
schools, were destroyed or lost ; but as society emerged from the 
darkness which overshadowed its intelligence, we see the thread 
at once taken up and followed, though languidly and without 
vigor, to the beginning of the nineteenth century. 

Toward the middle of the seventeenth century we find very 
special and full allusion made to the speculum and its uses by 
Ambrose Pare and Scultetus ; the instrument being very well 
represented by diagrams, with descriptions attached. 



Fig. 1. 





Ancient valvular specula. (Scultetus.) 



"Fig. 1," says the author, ~" is an instrument which they call 
'speculum ani et vaginas uteri,' in that by its help ulcers of the 
rectum, vagina, and uterus may be seen, to be carefully observed 
according to their extent and kind." {Scultetus.) 

Aetius and Paulus evidently knew of a tubular speculum, since 
they say, "lest the tube of the speculum be too long," &c; but 
Scultetus figures a bi- valve and quadri- valve closely resembling 
those in our hands at present. It is worthy of mention, in this 
connection, that there is now preserved in the Museo Borbonico 



OF UTEEINE PATHOLOGY. 39 

at Naples a bi-valve speculum which was removed from the 
ruins of Pompeii. 

It has already been stated that Aetius makes an obscure refer- 
ence to a sound for replacing the uterus. This is by no means 
the first notice of this useful instrument, for it is repeatedly men- 
tioned by Hippocrates, and Avicenna, the Arabian, likewise alludes 
to it. Prof. Simpson 1 asserts, however, that it was used only for 
dilatation of the cervix, and not for exploration and measurement. 
In 1657 a probe, used as we now employ the uterine sound, and 
intended especially for uterine exploration, was accurately de- 
scribed by Wierus, 2 and alluded to by Hilken, Cooke, and others. 

As we pass in review the chief works which appeared upon 
our subject in the eighteenth century, we find frequent mention 
of the speculum, which is spoken of as a matter of course in 
the treatment of uterine affections, and yet was evidently not so 
employed as to render it really a valuable aid in diagnosis or 
treatment. This constitutes one of the most curious episodes 
met with in the history of any discovery with which we are 
acquainted. A most simple and useful instrument was not only 
well known in ancient times and subsequently fell into disuse, but 
fell into disuse without having ever been really forgotten. It was 
described by successive writers up to the nineteenth century in 
language as distinct as words could make it, and yet not only 
did they who read, but they who wrote it, not comprehend 
its meaning or appreciate its significance. Like the Indians 
possessed of the diamond, all saw and yet none valued. How 
could Ambrose Pare, for example, writing in 1640, have indicated 
its use more clearly than when he tells us, in chapter xix., that 
ulcers of the womb may be recognized, "by the sight, or by put- 
ting in a speculum" ? In a copy of his works in the library of 
Dr. W. A. Hammond the word speculum is italicized in this sen- 
tence. Scultetus, as we have seen, not only described but figured 
the instrument in 1683. 

In 1761, Astruc, 3 " Eoyal Prof, of Physic at Paris," in de- 
scribing occlusion of the vagina and obstruction to the menstrual 
flow, says: "There is nothing more required than to examine 

1 Obstetrical Works. 

2 Dr. H. G. Wright, Joe. cit. 

8 Dis. of Women, Eug. ed., vol. i. p. 135. 



40 HISTOEICAL SKETCH 

the vagina by introducing the finger into it, rubbed previously 
with oil or pomatum ; but, if that be not sufficient, a speculum 
uteri may be used, or some other more simple instrument for 
dilatation, in order to be able, by means of the dilatation of the 
vagina, to judge by the sight of what, the touch could not 
decide." , 

In 1801, according to Becquerel, 1 forty years after this, Reca- 
mier " discovered the speculum." Nothing is farther from my 
mind than the wish to cast the slightest discredit upon the inte- 
grity of the labors of this great man, who was really the founder 
of the modern school of Gynecology; but after the evidence 
which I have adduced, I feel fully justified in asserting that the 
instrument was not his discovery. Guided by the advice found 
in many works which his library must have contained — works 
with which to suppose him not to have been perfectly familiar, 
would be to cast a slur upon his medical research — he employed 
a speculum vaginae in 1801. Like his predecessors, he did not 
appreciate the great results which were to flow from it ; nor did 
he appear to have regarded himself as having invented it. It 
was not until 1818 that he introduced it to the profession, and 
gave it its place as a valuable addition to science. Can any one 
suppose that it could have required seventeen years of experi- 
mentation and study for a man, with the talent of Recamier, to 
have applied this simple and useful instrument to purposes of 
utility ? Is it not more likely that the experience of seventeen 
years taught him the full value of the instrument ? The credit 
which belongs to Recamier is not that of a discoverer, but that 
which is equally great, of having recognized the value of what 
was well known, but badly appreciated before his time. 

Even before this fortunate revival, as the eighteenth century 
approached its close, the glimmer of the new era which was 
about to dawn, could clearly be detected in the advanced views 
which were promulgated by Garangeot and Astruc in France, 
and Denman, John Clark, and Hamilton in England. The early 
part of the nineteenth century found the field occupied chiefly 
by Sir Charles Clarke and Dr. Gooch in England, and Recamier 
and Lisfranc in France. These were not the only eminent writers 

1 Mai. de 1' Uterus, vol. i. p. 9. 



OF UTERINE PATHOLOGY. 4L 

of that time, but they were unquestionably those who chiefly 
moulded professional opinion. 

Even at that period Gynecologists ranged themselves into two 
parties, which, so late as at our day, have scarcely coalesced. In 
England the feeling was strongly in favor of regarding the local 
disorder as the result and not the cause of concomitant constitu- 
tional derangement; while in France the uterine disease was 
viewed as the main element, and the general condition as de- 
pendent upon and resulting from it. 

The great advantages of the speculum secured its rapid adop- 
tion in France. More slowly it forced its way through many 
prejudices into Great Britain, and before a great many years had 
passed it was, throughout the civilized world, placed upon an 
enduring basis as one of the boons bestowed by medicine upon 
humanity. The way being opened for investigation by this 
instrument, new aids to diagnosis and treatment were rapidly 
advanced. In 1826 Guilbert read before the Academy of Medi- 
cine of Paris an essay proposing the application of leeches to the 
cervix. In 1828 Samuel Lair read before the same body a paper 
in which he counselled the use of the uterine sound. In 1832 
M. Melier presented an essay, in which he offered two new sug- 
gestions in the treatment of uterine diseases — one, injections into 
the cavity of the cervix; the other, local applications in the 
vagina by dossils of lint saturated with astringents, narcotics, 
&c. His views are quoted extensively by French writers, and 
Konat says that the author recognizes, "avec une franchise qui 
l'honore," that Boyle, Chaussier, Guillou, and others, had a short 
time before him used similar means. Yery curiously neither 
Melier nor his commentators mention that both these sugges- 
tions are made and fully elaborated by Astruc, in his excellent 
article upon " Ulcers of the Uterus." He describes these appli- 
cations of medicated charpie very carefully, remarking that 
it is advisable to "tie a thread to every pledget, in order to draw 
it out again when it is proper to renew the dressing." And he 
not only advises injections of water, impregnated with different 
substances, into the cavity of the womb, but also the juices of 
plantain, houseleek, nightshade, &c. "For," says he, "as it is 
of consequence that these injections should enter into the uterus, 
where the ulcer has its seat, it is proper they should be made by 



42 HISTOEICAL SKETCH 

a professor of midwifery, capable of introducing skilfully the end 
of the canula into the orifice^of the uterus," &c. 

At this time arose the question as to cancer of the uterus, 
whether it was the local manifestation of a general blood state, 
or the result of an inflammatory engorgement long neglected; 
a question which excited warm discussion, and brought forth the 
most opposite views. 

The ambition of Eecamier was not satisfied with exposing the 
cervix uteri to view. He had the boldness to explore the cavity 
of the body of the organ, almost establishing the use of the 
sound, and even, by means of a species of scoop called a curette, 
ventured in certain cases to scrape off its investing mucous mem- 
brane. In addition he described, through one of his students, 
pelvic cellulitis, and gave the first intimation which modern 
observers have had of the possibility of pelvic hematocele. 

These discoveries on the part of the French physician mark 
an era in Gynecology ; one no less important was created by the 
appearance in the field of labor of Professor, now Sir James 
Simpson, of Edinburgh. About the year 1843 he rapidly deve- 
loped and recommended to the profession several of the most 
important means of diagnosis now at our command. The utiliza- 
tion of the uterine sound, which Lair had never succeeded in 
introducing into general practice, and the dilatation of the canal 
of the cervix by sponge-tents, so that the body may be exam- 
ined, are both due to his genius and enterprise. He likewise 
contributed from time to time original and valuable papers upon 
pelvic cellulitis, haematocele, uterine flexions, &c. His articles, 
indeed, first excited the study of uterine displacements in Great 
Britain, and to his efforts may be traced, in a great degree, the 
interest which has been of late years aroused in that country with 
reference to uterine pathology. Until this time the subject had 
attracted very little attention there, and advances which had been 
made in it were due almost entirely to French pathologists. It 
is true that the excellent work of Sir Charles Clarke existed; 
but that warm and zealous interest which has since resulted in so 
much benefit to Gynecology, had not then been excited. But 
Prof. Simpson was not alone in this work. Dr. J. H. Bennet, of 
London, at that time a young physician, who had for some years 
served as interne in the hospitals of Paris, returned to his own 



OF UTERINE PATHOLOGY. 43 

country imbued with the views which Recamier and Lisfranc had 
disseminated among a large circle of followers. In 1845 the first 
edition of his work on Inflammation of the Uterus appeared, 
and it is safe to assert that no work of modern times, written 
upon any subject connected with our profession, has exerted a 
more decided and profound influence. Taking up the subject 
with a vigor and energy which forced attention, if not conviction, 
he produced an undeniable impression upon the profession, not 
only in his own country, but in Germany, France, and America. 
However others may differ from him, no candid mind can deny 
him the obligation under which he has placed his brethren by 
arousing their attention and directing their investigations into 
proper channels. The chief points insisted upon in his work are 
these: 1. That inflammation is the primum mobile in uterine 
affections, and that from it follow as results, displacements, 
ulcerations, and affections of the appendages. 2. That menstrual 
troubles and leucorrhcea are merely symptoms of this morbid 
state. 3. That in the vast majority of cases, inflammatory action 
will be found to confine itself to the cervical canal, and not to 
have affected the cavity of the body. 4. The propriety of attack- 
ing the disease in its habitat by strong caustics. 

About this time a discussion sprang up between Dr. Bennet 
on one side, and Drs. Robert Lee, West, and Tyler Smith on 
the other, with reference to the true character of ulceration of 
the neck; Dr. Bennet supporting the view that the cervix is 
often affected by inflammatory ulceration, and his opponents 
denying it. The discussion, looked at calmly by posterity — nay, 
even at the present time — will be pronounced a polemic disputa- 
tion, which has not served to clear up the subject, nor to have 
accomplished any really good end. 

One further benefit which Dr. Bennet conferred in his work, 
was in placing upon a surer basis than it had yet occupied, the 
differentiation of inflammatory engorgement and induration from 
commencing cancer of the neck. 

It would be well before proceeding farther to state as succinctly 
as possible the different pathological views which from this time, 
and even somewhat before it, were offered to the profession, and 
more or less generally adopted. 

They may be thus enumerated : — 



44 HISTORICAL SKETCH 

1st. That inflammation is the starting point of most of the 
affections of the uterus, and that a large number of evils follow 
this morbid state as results. 

2d. That uterine disorder is dependent upon a constitutional 
derangement, and would yield without other treatment than that 
directed to the removal of the general condition. 

3d. The view of Dr. Bennet, which is similar to the first men- 
tioned, with this additional point, that metritis generally limits 
itself to the neck, and only exceptionally affects the body. 

4th. The view of Dr. Tyler Smith, that leucorrhcea arising 
from glandular inflammation in the cervix is the cause of granu- 
lar degeneration of this part, and of subsequent engorgement. 

5th. The view that uterine disorders often, if not generally, 
commence in displacement, which is a primary and not a sec- 
ondary condition, and that to relieve the train of morbid symp- 
toms, this, its exciting cause, should be first removed. 

6th. The view that uterine disorder is commonly the result of 
ovarian inflammation, which reacting on the womb is the prime 
mover, in many cases, of its morbid states. 

I have no intention of discussing here the merits of these the- 
ories, but will limit myself to a few words connected with the 
history of each. 

The theory mentioned first in this enumeration is the oldest on 
record, the writers of the Greek School even adopting it. Thus 
Paulus JEgineta heads his chapter on this subject, "Inflammation 
of the uterus and change of its position." One of the symptoms 
of such inflammation he considers to be retroversion of the 
uterus. In the beginning of the present century this was gene- 
rally accepted in France. Lisfranc and Kecamier adopted it, and 
it was transferred to, and advocated in Great Britain by the writ- 
ings of Dr. Bennet. I do not believe that I state too much in 
asserting that the great majority of Gynecologists in this country 
accord in it ; though of course I admit that the statement is open 
to error, as every other statement of this kind is when not forti- 
fied by statistical proof. 

No one can devote himself to the practical study of uterine 
diseases without being impressed with the strong grounds which 
exist for the maintenance of the second of the theories mentioned. 
No grave uterine trouble affects the system for any length of time 






OF UTERINE PATHOLOGY. 45 

without reacting to a greater or less extent upon the general 
health. The nervous system becomes greatly disordered, the 
functions under its influence are badly performed, and derange- 
ment in hasmatosis is the invariable result. As the local disease 
often approaches stealthily, and may exist for a length of time 
without exciting suspicion, what is more natural than that many 
should view it as one of the numerous results of the general de- 
preciation? These three facts, however, which will constantly 
repeat themselves, as often, I may say, as favorable cases offer 
for testing the question, will, I think, very generally lead to a dis- 
trust of the doctrine : 1st, the fact that uterine disease and constitu- 
tional derangement existing together, a cure can rarely be effected 
by general means alone ; 2d, that the uterine affection being re- 
moved, the general state is at once improved; and, 3d, that those 
general conditions which prostrate the vital forces to the last 
extreme, as, for instance, tuberculosis, uraemia, scurvy, leuco- 
cythemia, &c, destroy life without ever showing, unless as an ex- 
ception, the local disease as " a fragment of the constitutional 
malady." 

The third of the theories mentioned has been already suffi- 
ciently spoken of. Those parts of it which are peculiar to Dr. 
Bennet will be fully dealt with elsewhere. 

The theory of Dr. Tyler Smith 1 I lay before the reader in his 
own words: "It is my conviction, notwithstanding, that in the. 
majority of cases in which morbid states of the os and cervix are 
present, cervical leucorrhcea, or, in other words, a morbidly aug- 
mented secretion from the mucous glands of the cervical canal, 
is the most essential part of the disorder, and that the diseased 
conditions of the lower segment of the uterus, which have been 
made so prominent, are often secondary affections resulting from 
the leucorrhceal malady." This theory was by no means a new 
one, when advanced as above mentioned, for Lisfranc 2 mentions 
it thus: "Observation proves that leucorrhcea can in the first 
place cause uterine engorgements, and that later it may be kept 
up by them ; it occasions them often." 

Lisfranc, however, says "often," while Dr. Smith says, "in the 
majority of cases." But even before Lisfranc it had attracted 

1 On Leucorrhoea. 2 Clin. Chirurg., vol. ii. p. 303. 



46 HISTORICAL SKETCH 

attention, for Paulas ^Egineta 1 gives "defluxion" as one of the 
causes of "ulceration of the womb." That an acrid leucorrhoeal 
discharge will create abrasion of the os, follicular vaginitis, ure- 
thritis, pudendal inflammation, and pruritus, no one will deny, for 
we see similar irritations occurring on the upper lip in nasal 
catarrh in children, which sometimes spreads as an eruption over 
the whole face ; but the leucorrhoea regarded by Dr. Smith as the 
primary disease is only a symptom of cervical endometritis, which 
often causes inflammation in the deep tissues of the cervix, and 
results in enlargement and induration. The views of Dr. Smith 
were brought forth at a time when Dr. Bennet was pressing the 
theory of inflammation as the keystone of uterine pathology, and 
in combatting the idea of parenchymatous inflammation, he merely 
recorded the fact that it is often preceded by, and results from 
the same process taking its rise in the mucous lining of the canal. 
Dr. Smith's position was maintained with all that ability and force 
which have rendered him so popular as an author amongst us in 
America, and the influence of his writings upon uterine patho- 
logy can be at present clearly traced in this country. 

In the year 1854 a discussion, which soon assumed extensive 
proportions and elicited great warmth, arose in the Academy of 
Medicine of Paris, with reference to the treatment of uterine dis- 
placements. M. Yelpeau stood forth as champion of the view which 
is here expressed in his own words. "I declare, nevertheless, that 
the majority of the women treated for other affections of the ute- 
rus have only displacements, and I affirm that eighteen times out 
of twenty, patients suffering from disease of the womb, or of some 
other part of this region, those for instance in whom they diag- 
nose inflammation (engorgements), are affected by displacements." 
In this and subsequent discussions he was upheld by some of the 
first physicians of Paris, and by many the view then expressed is 
still adhered to. It has resulted in a vast number of mechanical 
contrivances, called pessaries, to restore the organ to its place in 
the hope of thus striking the pathological series at its root. Intra- 
uterine, vaginal, and abdominal supporters have been employed, 
and attempts have been made to offer support even through the 
rectum. 

1 Op. cit., p. 624. 



OF UTERINE PATHOLOGY. 47 

I was present during the discussion in Paris in 1854, and being 
engaged in the report of it for an American medical journal, 1 paid 
strict attention to its progress. Influenced by the arguments which 
it elicited, and by the teachings of Valleix, whom I daily followed 
at La Pitie, I was convinced of the truth of Velpeau's position. 
Experience, however, has led me to dissent from it. I have found 
most of my cases of displacement, which were attended by evil 
symptoms, to be accompanied by marked evidences of inflamma- 
tion; have found them usually susceptible of no permanent benefit 
from replacement ; and have obtained relief from.the symptoms for 
which I was called, chiefly by means which cured uterine inflam- 
mation. I have noticed that similar displacements almost invaria- 
bly result from inflammation which commenced when the uterus 
was in its proper place ; and have seen complete retroversion of 
the womb, where no inflammation existed, produce, after the 
patient had become accustomed to it, no sympto 
These observations have led me to discard the belief in the mere 
dislocation as the first link in the chain, and caused me to regard 
it as generally a result of anterior inflammation. 

The peculiar and very marked sympathy existing between the 
uterus and ovaries has given rise to the theory mentioned last in 
the enumeration. I meet very often, as' I suppose every practi- 
tioner does, with cases of simple uncomplicated uterine disease 
in which the patient has been treated for ovarian disorder, which 
is presumed to have been the cause of the uterine ailment. So 
often do I meet them, indeed, that I cannot but regard the belief 
in this view as very prevalent in America. Frequently it is used 
as a cloak for ignorance, the physician fixing upon it from his 
inability to elucidate the real pathological features of the case. 
At other times sensitiveness over the ovaries, with enlargement, is 
regarded by capable men as producing a series of evils, no special 
attention being paid to coexisting metritis, which is viewed 
merely as a complication. There can be no doubt that ovarian 
inflammation, which is clearly diagnosticable, gives rise to main 
of the symptoms of uterine disorders, but under these circum- 
stances a carefully made differential diagnosis will generally set- 
tle the point. Nor is it less certain that uterine diseases verj 

1 The Charleston Medical Journal for 1S54. 



48 HISTORICAL SKETCH 

frequently produce sympathetic trouble in the ovaries, resulting 
in great sensitiveness upon pressure, and sometimes enlargement. 
As, however, in this Case no treatment directed to the ovaries will 
remove existing uterine disease, while curing the latter will gene- 
rally remove the ovarian affection, it appears to me that in the 
present state of our pathological knowledge we are forced to con- 
clude that if certain symptoms diagnostic of uterine or ovarian 
disease exist, and an examination shows a uterine lesion, with evi- 
dences of ovarian enlargement and sensitiveness, it is safe to 
decide that the latter state is the result of the former ; but if no 
uterine disease is discoverable, and the ovarian symptoms alluded 
to exist, we are warranted in believing that ovarian disorder gives 
rise to them. 

Of late years rapid advances have been made in the surgical 
treatment of the diseases of women. Under the lead of Marion 
Sims, Spencer Wells, Baker Brown, Clay of Manchester, Emmet 
and Bozeman of New York, and the Atlees of Philadelphia, opera- 
tions for ovariotomy, the cure of ruptured perineum, vesico- vaginal 
fistulas, constriction, or tortuosity of the cervix, etc., have been 
perfected and are now in constant practice. 

France and Great Britain have laid the world under obligation 
by the advances made during the last half century in Gynecology. 
Germany has done little in comparison, though works which are 
pronounced of great merit, by those to whom this literature is 
open, have been produced by Siebold, Mende, Meissner, Kiwisch, 
Lumpe, and Oppolzer. The work of Scanzoni, translated by Dr. 
Gardner, of this city, is well known to all, and Dr. John Clay, of 
Birmingham, has rendered service by his able translation of the 
chapters of Kiwisch's work on the " Pathology and Treatment 
of the Diseases of Women," which relate to affections of the 
ovaries. 

It is a great source of pleasure to me before closing this sketch 
to be able to record the fact that America has not been wanting 
in her contribution towards the progress of this branch of medi- 
cine. It is to this country that is due the credit, not only of the 
first performance of ovariotomy in 1809, by Dr. Ephraim McDo- 
well, of Kentucky, but its subsequent development into a syste- 
matic operation by his compatriots. It was never even attempted 



OF UTERINE PATHOLOGY". 49 

in Great Britain until 1823. No successful case was ever per- 
formed in London until 1842, in Scotland only one successful case 
was reported up to 1862, and in Ireland, at that time, not one suc- 
cess was on record. 1 In the mean time it had taken deep root in 
America; even as early as 1830 Dr. McDowell having performed 
it thirteen times, with eight favorable results, and before 1862 
Dr. Atlee had achieved that eminence, as 'an operator, which he 
now enjoys. 

I have elsewhere called the results of the labors of Recamier 
and Simpson eras in the progress of this department. I now 
venture so to style those of Marion Sims. In doing this I make 
no reference to the improvements inaugurated by him in the treat- 
ment of injuries to the genital organs ; my allusion is to the great 
advantages which now flow and are to flow from the invention of 
his speculum, which exposes the uterus by a new principle, and 
opens the way to a more complete examination of that organ. 
Recamier marked an era by improving our powers of diagnosis 
in exposing the cervix uteri ; Simpson another, by opening to 
investigation the body of the uterus ; and Sims a third, by render- 
ing both investigations more simple, complete, and satisfactory. 
The ordinary specula in use before the discovery of Sims's simply 
separate the vaginal walls mechanically, and thus expose the ute- 
rus. Sims's instrument, on the other hand, elevates the posterior 
vaginal wall, which allows the entrance of air to distend the whole 
passage, the woman lying on her side in such a manner that the 
cavity can be probed with the most perfect ease, and applications 
made to the fundus. I am fully aware that many will differ from 
me in this opinion, but being entirely free from prejudice in favor 
of this instrument, or against the ordinary varieties, I maintain 
it fearlessly, feeling confident that time will prove it to be correct. 
No one who has not tested the two methods of examination is 
really entitled to an opinion upon the point, and I cannot 
doubt the conclusion of him who has done so faithfully and 
intelligently. 

Within the last twenty j^ears a vigorous attempt has boon 
made to open the field of Gynecology to female labor, and to 
place it and its sister branch, obstetrics, to as groat an extent as 

1 Peaslee on Ovariotomy. 



50 HISTORICAL SKETCH 

possible, under the management of female practitioners. To this 
end female medical colleges have been established in Geneva, 
New York, Philadelphia, and other cities of America ; and of 
late the English journals inform us of the foundation of one in 
London. ' In France a proportion of the work has, for a long- 
time, been allotted to the "Sages Femmes," or midwives. Many 
of those who foster the attempt appear to regard it as a novel 
one, and reiterate the assertion that woman has never been 
allowed a fair trial in this, her most appropriate sphere of action. 
This is a great error. Not only has the way been open to her as 
competitor with man, but at times it has been almost entirely 
relinquished to her keeping. If success has not attended her 
efforts, it has been due, not to want of opportunity, but of capacity 
or adaptation. Aetius makes mention of the writings and prac- 
tice of Aspasia, who was a doctress at Eome about the third 
century, and copies extensively from her upon ulceration and 
displacements of the womb. Paulus JEgiaeta is, for some of his 
chapters, indebted to Cleopatra, fragments of whose writings he 
has preserved to us. He evidently quotes her with respect, and 
credits her with what he borrows. In the thirteenth century an 
Arabian woman, Trotula by name, published a treatise, in which 
she mentions that many Saracenic women practised the art of 
obstetrics at Salerno. The women of Greece and Eome ap- 
proached the task much better prepared to meet its requirements, 
both mentally and physically, than do those of our day; and 
surely no lack of opportunity could have been complained of by 
the successors of Agnodice. 1 Those of the Arabian civilization 
had not only opportunity, but the incentive of necessity, to urge 
them on to the acquirement of knowledge and skill ; for so great 
were the sensuality and libertinism of the Saracens, that the 
Mahommedan laws prohibited the attendance of males upon 
females ; and thus the whole dut}^, except in extreme cases, 
devolved upon the midwives. 

No one of extended views can desire to see the doors of science 

1 The story of this physician is worthy of note. Contrary to the existing laws, 
she studied medicine, met with great success under the disguise of a man, was 
accused of corruption and brought to trial. Making her sex known to the judges, 
she was not only acquitted, but a law was passed allowing all free-born women to 
study medicine in future. 



OF UTEKINE PATHOLOGY. 51 

shut to any who are sincere in their wishes to engage in its pur- 
suits; nevertheless, there is no resisting the evidence of history, 
that, in spite of opportunities and incentives, female practitioners 
have failed, in times past, not only to advance, but even to main- 
tain the integrity of the art intrusted to their hands. The expe- 
rience of the future may belie that of the past ; but even its doing 
so will offer no good reason for despising the lesson which the 
past has left on record. 

I am so often consulted by recent graduates as to the works 
which they should make the basis of a library upon Gynecology, 
that I feel that I may render a service by the following list. 
Only such works are recorded as will prove of absolute service 
to the active practitioner who seeks knowledge chiefly upon 
practical points: — 

Nonat — Maladies de 1' Uterus, 1 vol. 

Aran — " " 1 vol. 

Becquerel — " " 2 vols. 

Blatin et Nivet — Maladies des Femmes, 1 vol. 

West — Diseases of Women, 1 vol. 

Tilt — Uterine and Ovarian Inflammation, 1 vol. 

Bennet — On the Uterus, 1 vol. 

Simpson — Diseases of Women, 1 vol. 

Hewitt— " " 1 vol. 

Churchill— " " 1 vol. 

Byford — Medical and Surgical Treatment of Women, 1 vol. 

Sims — Uterine Surgery, 1 vol. 

Baker Brown — Surgical Diseases of Women, 1 vol. 

Tilt — Uterine Therapeutics, 1 vol. 

Scanzoni — Diseases of Females, 1 vol. 

Meigs — Diseases Peculiar to Females, 1 vol. 

Bedford — Diseases of Women and Children, 1 vol. 

Colombat — On Females (annotated by Meigs), 1 vol. 

Ashwell — Diseases of Women, 1 vol. 

McClintock— " " 1 vol. 

Courty — Maladies de PUterus et de ses Annexes, 1 vol. 

Hodge — Diseases of Women, 1 vol. 

Klob — Pathological Anatomy of the Female Genital Organs, 1 vol. 

Spencer Wells — On Diseases of the Ovaries, 1 vol. 

Kiwisch — " " " 1 vol. 

Elliot — Obstetric Clinic, 1 vol. 



CHAP TEE II. 

THE ETIOLOGY OF UTEKINE DISEASES IN AMEEICA. 

In investigating the causes of uterine diseases which are active 
in this country, I would not be understood as drawing any com- 
parison between their frequency here and abroad, for in the ab- 
sence of statistical evidence such an attempt would necessarily be 
futile. It is easier to write of habits which are under our imme- 
diate observation, than of those concerning which we merely 
read and hear, and for this reason I give myself the limits herein 
prescribed. My intention is not to review all the causes of ute- 
rine disorders, but to confine myself to the consideration of those 
which are avoidable, incurred merely from disregard of the laws 
of health, and which are generally rather predisposing than ex- 
citing. Others, which are accidental and exciting, will be men- 
tioned in connection with special diseases as they come under 
notice. 

If we compare the present state of women in refined society 
over the world with that of the working peasants of the same 
latitudes, or with the North American squaws or the powerful 
negresses of the Southern States, we can with difficulty believe 
that they all sprung from the same parent stem, and originally 
possessed the same physical capacities. Observation proves that 
women who are not exposed- to depreciating influences can com- 
pete in strength and endurance with the men of their races, and 
in savage countries they are sometimes regarded as superior to 
them. In the lower orders of animals this equality is still more 
marked. The mare endures as much as the horse, and some of 
our most celebrated racers have represented the female sex. The 
lioness is fully as dangerous to the hunter as her more majestic 
consort, and the bitch proves as untiring in the chase as the 
most muscular dog in the pack. 

From all these facts we may logically argue, that the human 
female, if properly developed and placed beyond causes which 



WANT OF AIR AND EXERCISE. 53 

militate against her physical well-being, would be in no great 
degree the inferior of the male. This position I now assume, 
and maintain that the customs of civilized life have depreciated 
her powers of endurance and capacity for resisting disease. My 
efforts will be directed to an endeavor to point out what these 
habits and influences are. 

Those which are most prominent and universal may thus be 
enumerated: — 

Want of fresh air and exercise. 

Excessive development of the nervous system. 

Improprieties of dress. 

Imprudence during menstruation. 

Imprudence after parturition. 

Prevention of conception and induction of abortion. 

Marriage with existing uterine disease. 

Want of air and exercise, in deteriorating the blood and enfee- 
bling the muscular and nervous systems, should be classed first 
among these predisposing causes. 

There can be no doubt that American women take much less 
exercise than those of Europe. Walking, riding, rowing, bowl- 
ing, &c, which are there so common, are here not much prac- 
tised. In our large cities will be found hundreds of ladies who 
do not walk a mile in a day for weeks together, and many more 
who have never engaged in any exercise which called forth the 
action of other muscles than those employed in the quietest loco- 
motion. This is partly due to the fact that, with us, recreations 
which require muscular efforts on the part of women are not 
fashionable ; partly to a morbid desire to cultivate an appearance 
of delicacy of form and complexion ; and in great part to impro- 
prieties of dress, which render it dangerous for them to remain in 
the open air except in good weather. Instead of our girls being 
encouraged to engage in out-door pursuits calculated to create 
muscular power, they are reared in the belief that such pastimes 
are hoydenish, unbecoming, and fit only for rough boys. Their 
hours of leisure are occupied by reading, music, drawing, or some 
similar light task, and an hour's walk every day is regarded as an 
accomplishment quite creditable to the performer. This perni- 
cious system of training is observed most markedly in our largo 



54 ETIOLOGY OF UTERINE DISEASES. 

female seminaries or boarding schools, where every hour of the 
day is allotted by rule to its especial work. By this plan the 
mind is constantly kept in the thraldom of control, and chafes 
under the depressing influence of a never-ending surveillance. 
A set of romping school-girls could as profitably laugh by rule 
as really enjoy and improve by exercise under the eye of an in- 
structress or professor of calisthenics. It is not the mere bodily 
exertion which is of benefit, but the total mental relaxation, the 
exhilaration and the abandon which accompany it. The prisoner 
working for eight hours on the tread-mill does not profit by it as 
the free and happy equestrian or oarsman does, by one-eighth the 
time of exercise. 

Excessive Development of the Nervous System. — The necessity for 
a due proportion existing between the development and strength 
of the nervous and muscular systems has always been recognized, 
and has given rise to the trite formula, " mens sana in corpore 
sano," as essential to health. Unfortunately the restless, ener- 
getic and ambitious spirit which actuates the people of the 
United States, has prompted a plan of education which by its 
severity creates a vast disproportion between these two systems, 
and its effects are more especially exerted upon the female sex, 
in which the tendency to such loss of balance is much more 
marked than in the male. Girls of tender age are required to 
apply their minds too constantly, to master studies which are too 
difficult, and to tax their intellects by efforts of thought and 
memory which are too prolonged and laborious. The results are, 
rapid development of brain and nervous system, precocious talent, 
refined and cultivated taste,, and a fascinating vivacity on the 
one hand ; a morbid impressibility, great feebleness of muscular 
system, and marked tendency to disease in the generative organs, 
on the other. 

That this statement of the advantages which are gained and 
the price which is paid for them is perfectly true, no American 
practitioner will deny. Bat the mere existence of the fact is not 
the most melancholy feature of the case ; it is far more painful 
to see mothers listening to it, admitting its truth, and yet calmly 
and dispassionately choosing to make the trial, as we see them 
doing every day. 



IMPROPRIETIES IN DRESS. 55 

Improprieties of Dress. — The dress adopted by the women of 
our times may be very graceful and becoming, it may possess 
the great advantages of developing the beauties of the figure 
and concealing its defects, but it certainly is conducive to the 
development of uterine diseases, and proves not merely a predis- 
posing, but an exciting cause of them. For the proper perform- 
ance of the function of respiration, an entire freedom of action 
should be given to the chest, and more especially is this needed at 
the base of the thorax, opposite the attachment of the important 
respiratory muscle, the diaphragm. The habit of contracting the 
body at the waist by tight clothing confines this part as if by 
splints; indeed, it accomplishes just what the surgeon does who 
bandages the chest for a fractured rib, with the intent of limiting 
thoracic, and substituting abdominal respiration. 

As the diaphragm, thus fettered, contracts, all lateral expansion 
being prevented, it presses the intestines upon the movable uterus, 
and forces this organ down upon the floor of the pelvis, or lays 
it across it. In addition to the force thus exerted, a number of 
pounds, say from five to ten, are bound around the contracted 
waist, and held up by the hips and the abdominal walls, which 
are rendered protuberant by the compression alluded to. The 
uterus is exposed to this downward pressure for fourteen hours 
out of every twenty-four ; at stated intervals being still further 
pressed upon by a distended stomach. 

In estimating the effects of direct pressure upon the position of 
the uterus, its extreme mobility must be constantly borne in 
mind. No more striking evidence of this can be cited than the 
fact that, in examining it by Sims's speculum, if the clothing is 
not* loosened around the waist, the cervix is thrown so far back 
into the hollow of the sacrum as to make its engagement in the 
field of the instrument often very difficult, and that attention to 
this point in the arrangement of the patient will at once remove 
the difficulty. While the uterus is exposed by the speculum, it 
will be found to ascend with ever}?- expiratory effort, and descend 
with every inspiration ; and so distinct and constant are the rapid 
alterations of position thus induced, that in operations in the 
vaginal canal the surgeon can tell with great certainty how 
respiration is being affected by the anaesthetic employed. An 
organ so easily and decidedly influenced as to position by such 



56 ETIOLOGY OF UTERINE DISEASES. 

slight causes must necessarily be affected by a constriction which, 
in autopsy, will sometimes be found to have left the impress of 
the ribs upon the liver, producing depressions corresponding to 
them. 

No one will charge me with drawing upon my imagination, 
even in the remotest degree, for the details of the following pic- 
ture, for a little reflection will assure all of its correctness. A 
ladv who has habitually dressed as already described, prepares 
for a ball by increasing all the evil influences which result from 
pressure. Although she may be menstruating, she dances until 
a late hour of the night, or rather an early hour of the morning. 
She then eats a hearty supper, passes out into the inclement 
night-air, and rides a long distance to her home. This is repeated 
frequently during each season, until advancing age or the occur- 
rence of disease puts an end to the process. 

A great deal of exposure is likewise entailed upon women by 
the uncovered state of the lower extremities. The body is 
covered, but under the skirts sweeps a chilling blast, and from 
the wet earth rises a moist vapor, which come in contact with 
limbs encased in thin cotton cloth, which is entirely inadequate 
for protection. It is not surprising that evil often results to a 
menstruating woman thus constantly exposed. 

To a woman who has systematically displaced her uterus by 
years of imprudence, the act of sexual intercourse, which in 
one whose organs maintain a normal position is a physiological 
process devoid of pathological results, becomes an absolute and 
positive source of disease. The axis of the uterus is not identical 
with that of the vagina. While the latter has an axis coincident 
with that of the inferior strait, the former has one similar to that 
of the superior. This arrangement provides for the passage of 
the male organ below the cervix into the posterior cul-de-sac, the 
cervix thus escaping injury. But let the uterus be forced down, 
as it is by the prevailing styles of fashionable dress, even to the 
distance of one inch, and the natural state of the parts is altered. 
The cervix is directly injured, and thus a physiological process 
is insensibly merged into one productive of pathological results. 
How often do we see metritis occur just after matrimony, e,ven 
where no excesses have been committed! It is not an excessive 
indulgence in coition which so often produces uterine disease, but 



IMPRUDENCE AFTER PARTURITION. 57 

the indulgence to any degree on the part of a woman who has 
distorted the natural relations of the genital organs. 

But this is by no means the only method by which displacement 
of the uterus may induce disease of its structures. It disorders 
the circulation in the displaced organ and produces passive con- 
gestion and its resulting hypertrophy, prevents the free escape 
of menstrual blood by pressing the os against the vagina, creates 
flexion, causes friction of the cervix against the floor of the pel- 
vis, and stretches the uterine ligaments and destroys their power 
and functions. 

Imprudence during Menstruation is a prolific source of disease. 
Some women through ignorance, many through recklessness, and 
a few from necessity, go out lightly clad in the most inclement 
weather during this period, and many suffer in consequence from 
violent congestive dysmenorrhcea, and often from endo-metritis. 
Every practitioner will meet with a certain number of cases of 
uterine disease which have this origin, and run on for years, 
ending, perhaps, in parenchymatous metritis, which may prove 
incurable. 

During a period in which the ovaries and uterus are intensely 
engorged, in which the peritoneum is broken through by the 
escaping ovule, and the nervous system is in an unusual state of 
excitability, ordinary prudence would suggest that the body 
should be well covered, that the congested organs should be left 
at r,est, and that exposure to cold and moisture should be sedu- 
lously avoided. I need not say that these rules are commonly 
neglected ; and in evidence of the fact I will venture the asser- 
tion that, on this very day, the thermometer 15° above zero, the 
skating-pond of our park contains scores of delicate and refined 
women who are showing a disregard of them by their presence 
there. 

Imprudence after Parturition. — No sooner does fixation of the 
impregnated ovum upon the uterine surface occur than a sur- 
prising stimulation is exerted upon the fibre-cells forming part 
of the uterine parenchyma, which grow with rapidity, enlarging 
the organ, pari passu, with the requirements of its increasing 
contents. After the expulsion of the embryo, either at full time 



58 ETIOLOGY OF UTEKINE DISEASES. 

or at any period of pregnancy, the fibres thus developed undergo 
a fatty degeneration and absorption, which has received the 
name of involution. This process occurs rapidly after abortion, 
but after labor at term it requires six weeks for its full accom- 
plishment. In order that it may proceed with normal rapidity 
and certainty, perfect rest is essential ; and the woman who rises 
too soon, and resumes her usual occupations while the lochial 
discharge is still existing, risks the results of interference with 
it. Besides this, the uterus is much heavier than usual, and the 
additional danger of the induction of displacement is incurred by 
too early movement. Lastly, the mucous membrane lining the 
cavity of the uterus is for some time after parturition in an ab- 
normal state, and is peculiarly liable to disease from exposure 
to cold and moisture. A very valid objection may be made to 
this view, that in the lower walks of life women rise after labor, 
and attend to their duties with impunity on about the ninth day, 
and yet enjoy a marked immunity from uterine affections. This 
is true; but let it be remembered that they are unaffected by 
the influences to which I have alluded, as calculated to enfeeble 
and deteriorate their generative systems. 

Prevention of Conception and Induction of Abortion. — Means 
established for the accomplishment of the first of these ends are 
often productive of uterine disorder. This will not be wondered 
at when the harshness of some of them is borne in mind. The 
workings of nature in this, as in all other physiological processes, 
are too perfect, too accurately and delicately adjusted, not to be 
interfered with materially by the clumsy and inappropriate mea- 
sures adopted to frustrate her laws. With this allusion we leave 
this unattractive subject to deal with one still more disagreeable, 
but which, from its importance, cannot conscientiously be passed 
over in silence. Statistics showing the frequency of criminal 
abortion have never been, and never will be written, for the 
crime creeps stealthily beneath the scrutiny of society, and, for 
some unaccountable reason, without material interference from 
the judiciary. It is, I feel, a bold statement, that, while the law 
pursues with relentless vigor the man who murders his fellow, 
it allows immunity to him who murders the young child in its 
mother's womb ; and yet it is well nigh correct. Let me point 



MARRIAGE WITH EXISTING UTERINE DISEASE. 59 

to a few facts which will substantiate this assertion, and the 
additional one that this crime is with us one of fearful fre- 
quency. On my table at this moment lies one of the most 
popular, respectable, and best edited daily journals of New 
York — one which finds its way into the first circles of society, 
and into the hands of maidens and matrons throughout the land. 
In its columns I count fifteen advertisements well known as 
being those of professional abortionists — men and women who 
make a business of infantile murder. It may be that the editors, 
who are esteemed amongst us as upright men, it may be that the 
police, are entirely ignorant of these facts; but it is hard to be- 
lieve so when many of these advertisements announce distinctly 
the advantages of their having rooms in which their patients 
may be accommodated, and that one interview always accom- 
plishes the desired result, without the use of means dangerous 
to life or health. At its last meeting in New York, the Ameri- 
can Medical Association offered a prize 1 for " a short and com- 
prehensive tract for circulation among females, for the purpose 
of enlightening them upon the criminality and physical evils of 
forced abortions." 

However much I may desire reformation in this matter, it is 
not in the spirit of a reformer that all this is written. I am not 
raising my voice against a great national crime, but am striving 
merely to establish the truth of my statement, that this crime is 
so frequent as to constitute in all classes of society — for it is 
limited to none — a great cause for uterine diseases. 

Marriage with Existing Uterine Disease. — It is a common prac- 
tice with physicians to recommend marriage as a cure for uterine 
disease. There are a sufficient number of abnormal conditions 
which child-bearing cures to make the practice appear legitimate, 
but a vast deal of harm frequently results from it. A displace- 
ment without inflammation, a constricted cervix which causes 
dysmenorrhea, a pure endo-metritis of neck or body, or an in- 
active state of the ovaries which results in amenorrhea, may 
be relieved by the parturient act ; but parenchymatous metritis 

1 The prize thus offered lias been awarded to Prof. H. R. Storer, of Boston, fox 

an able essay, entitled, " Why Not ?" 



60 ETIOLOGY OF UTERINE DISEASES. 

in any of its forms, peri-uterine cellulitis or pelvic peritonitis, 
will very often produce evil results after labor, and very gene- 
rally return with renewed violence as soon as involution has been 
accomplished. The advice is too often given empirically, and, 
like all such counsel, is hazardous in its results. My experience 
leads me to fear a return of metritis after child-bearing, even in 
a patient whom I considered entirely cured at the time of mar- 
riage; and in such cases I always predict it. 

Much injury has been done, and a strong position weakened by 
the insisting of over-zealous persons upon isolated causes as pro- 
ductive of injury to females. Chapter upon chapter has been 
written against tight-lacing, for instance, in so vehement a style 
that the reader, if she did not reflect, might suppose that to this 
abuse could be traced the whole catalogue of feminine ills. If 
perchance, however, she inspected the unyielding stays which 
once compressed the sturdy form of Alice Bradford, and which 
are now preserved in Pilgrim Hall in Plymouth, she would at 
once see that the indictment was not a valid one ; and similar 
objections might be raised against all the other causes which I 
have advanced, viewed as isolated influences. 

The Indian squaw or Southern freedwoman may go half naked 
while menstruating, carry heavy burdens from morning till 
night, or rise to labor or to travel in a day or two after parturi-. 
tion, and yet no evil will result ; but to the civilized woman any 
one of these imprudences may prove a source of disease. It is 
the combination of evil influences, or the action of a single cause 
on a system so deteriorated by others as to be made incapable of 
resisting it, which produces the unhappy climax. 

No one will doubt the conclusion, that if in cold weather the 
feet, legs, and abdomens of civilized women were clad in some 
woollen material — if they understood the necessity of caution 
during the period of menstruation and after labor — if they 
allowed the uterus to hold its proper place in the pelvis, unin- 
terfered with by pressure — if they kept the sanguineous and 
nervous systems in their normal state of vigor by exercise, 
fresh air, and plenty of good food, and at the same time avoided 
any habits which directly produced disease by injuring the geni- 
tal organs, much, very much less of uterine and kindred disorders 
would be seen by the physician. All these reforms would likely 



MARRIAGE WITH EXISTING UTERINE DISEASE. 61 

bring forth, results in one generation, but it would probably 
require many generations of reformers to restore woman to her 
proper physical sphere. 

Before any improvement is attained in this or any other 
matter, its importance must be estimated by, and a desire for it 
cultivated in, those whom it most nearly concerns. Neither ap- 
preciation of, nor desire for, physical excellence sufficiently exists 
among the refined women of our day. Our young women are too 
willing to be delicate, fragile, and incapable of endurance. They 
dread, above all things, the glow and hue of health, the rotundity 
and beauty of muscularity, the comely shape which the great 
masters gave to Yenus de Medicis and Yenus de Milo. All these 
attributes are viewed as coarse and unladylike, and she is re- 
garded as most to be envied whose complexion wears the livery 
of disease, whose muscular development is beyond the suspicion 
of embonpoint, and whose waist can almost be spanned by her own 
hands. As a result, how often do we see our matrons dreading 
the process of child-bearing as if it were an entirely abnormal and 
destructive one ; fatigued and exhausted by a short walk or their 
ordinary household cares ; choosing houses with special reference 
to freedom from one extra flight of stairs, and commonly debarred 
the great maternal privilege of nourishing their own offspring. 
These are they who furnish employment for the Gynecologist, 
and who fill our homes with invalids and sufferers. 



CHAPTEE III. 

DIAGNOSIS OF THE DISEASES OF THE FEMALE GENITAL ORGANS. 

The diagnosis of the diseases of the pelvic viscera of the 
female offers many obscurities, and frequently foils the most 
careful and capable practitioner. With the utmost caution, as- 
sisted by the most practised skill, no one can avoid occasional 
errors, while in the experience of those not possessing these quali- 
fications, they must be frequent and glaring. The only safeguard 
which can be established against their occurrence, and the only 
guarantee which can be obtained for success in prognosis and 
treatment, is the thorough mastery of the subject which is now 
to engage us. 

It is not rare for one making a special study of Gynecology to 
find those less familiar with it committing errors of diagnosis, 
or, what is more common, arriving at no conclusion, in cases 
which are perfectly simple and present no obscurities whatever. 
When meeting such instances in the practices of intelligent men, 
I have been struck by the fact that the source of difficulty is 
almost always the same. The failure of diagnosis has not been 
due to their having drawn incorrect conclusions from diagnostic 
means, but to their not having brought these means fully into 
action, and properly applied them to the solution of the case in 
hand. In many instances, uterine disease being suspected, the 
physician employs the vaginal touch, and follows it by the specu- 
lum. If the os and cervix be diseased, he is successful in diag- 
nosis ; but if not, he becomes discouraged, forgetful of the fact that 
the rectal touch, uterine probe, dilatation by tents, conjoined with 
manipulation and other means, should be resorted to, and that, 
without appealing to these, even the most skilful diagnostician 
would be as helpless as himself. There are means at our com- 
mand for exploring every tissue within the pelvis; the uterus, the 



KATIONAL SIGNS OF THESE DISEASES. 63 

ovaries, the areolar tissue, &c. ; and until they are brought into 
service carefully, systematically and thoroughly, no one can feel 
that he has done justice to his powers of diagnosis, or allowed 
himself a full opportunity for drawing correct conclusions. Skill 
in diagnosis must be obtained at the bedside, but for that school 
to be made profitable, the student must have a thorough famili- 
arity with the theory of the means of investigation which he is 
there to apply. 

Eational Signs of these Diseases. 

In the examination of a patient suspected of having uterine 
disorder no direct or suggestive questions should be asked, but 
the symptoms should be drawn forth by encouraging and pro- 
perly directing her narrative of her case. Certain signs which 
we call " rational," from their appealing to our reason and not to 
our senses, such as pain in the head, back, and limbs, menstrual 
disorder, leucorrhoea, impeded locomotion, derangement of the 
digestion and nervous manifestations, will lead us to suspect the 
genital organs, and may even convince us of the existence of dis- 
ease there. Generally, however, they result in the adoption of 
other and more certain means of diagnosis, which are termed 
" physical." 

Every one will, after due experience, adopt some system by 
which his examination of patients will be expedited, and the cer- 
tainty of arriving at a correct diagnosis be increased. The plan 
which I consider best adapted to these ends is that which 
follows : — 

1st. The personal history, age, &c, of the patient should be 
obtained. 

2d. The duration of the illness should be fixed. 

3d. The history of the attack from commencement to date 
should be elicited. 

4th. The present state of the patient should be ascertained. 

In obtaining the history of the disease, no leading questions 
have thus far been asked; the patient has told us what she herself 
has observed. Her evidence leads us to suspect some special dis- 
order, and then we proceed thus: — 

5th. Direct questions are put with the intent of testing the 
correctness of the suspicion which the patient's story has excited. 



64 MEANS OF DIAGNOSIS. 

6th. Physical means are brought to the corroboration of the 
diagnosis by rational ones. 

Forms, either written or printed, such as that which follows, 
will not only save a vast deal of time and trouble, but give uni- 
formity to histories taken, so that after a number of them have 
been accumulated they may be collated with reference to special 
points, or preserved for personal reference or publication. 



Case, No. Date, 



Name Age Married ? 

No. of children No. of abortions Time since last 

pregnancy Age at which menstruation appeared 

Duration of present illness Symptoms during its course 



Supposed cause 

Present condition as regards 

( Regularity. 

Menstruation, « Amount 

( Pain 



( Character.. 

Leucorrhoea, ■< Amount 

' Constancy. 

Pain, (Locality 

(Amount 



Locomotion 

Other symptoms. 



( By touch 

Physical signs, ■< By speculum 



By probe 



Diagnosis 



o 



Treatment . 



MANAGEMENT OF PATIENT DURING EXAMINATION. 65 

It will be observed that I have not enumerated the various 
rational signs generally attendant upon uterine affections, but 
merely the means for drawing them forth. Their special men- 
tion will be reserved for the study of particular affections. If 
the evidence elicited leaves any of the pelvic viscera under sus- 
picion, this is verified or removed by means which are more posi- 
tive and reliable from the fact that they address our senses. 

Management of Patient during Physical Examination. — 
Before commencing the consideration of physical signs, I shall 
premise a few remarks upon a subject of great importance in this 
connection, namely, the management of the patient during the 
examination. As Dr. Sims has taught us, she should never, unless 
it be impossible to do otherwise, be examined upon a bed or sofa, 
but upon a table covered with a blanket, shawl, or rug of some 
kind, and provided with a small pillow. The facility thus given 
for thorough investigation is very great, and the avoidance of 
the sinking of the body into the soft bed repays most fully the 
extra amount of trouble which it causes to make the change. 
It may be said that many ladies will strongly object to the expo- 
sure incident to getting upon a table. This is not so ; a little 
persuasion will overcome such objections at once, and the in- 
creased exposure is in reality imaginary, for the table is to all 
intents a bed, and a sheet for covering the person gives all desira- 
ble protection. Should it be necessary to employ a bed, the leaf 
of a dining-table, or a wide board should be slipped across the mat- 
tress under the upper sheet and covering, and a hard surface will 
thus be presented for the patient to lie upon, which will obviate, 
in a great degree, the objections to the bed otherwise arranged. 

The patient should always lie upon her back in a first exami- 
nation, with the clothing loose around the waist, the knees drawn 
up, and the abdominal walls relaxed. A sheet should be spread 
over her so as to conceal the entire person. The table having 
been previously turned to a window admitting a strong light, a 
chair should be placed at its foot for the examiner, and at the 
right side of it another, upon which has been arranged a basin of 
warm water, Castile soap and a towel. 
5 



66 MEANS OF DIAGNOSIS. 

MEANS OF PHYSICAL DIAGNOSIS. 

I shall enumerate and consider these in the order in which 
they will generally be resorted to in a case requiring the aid of 
all of them for its elucidation: — 

1. Ansesthesia. 

2. Vaginal touch. 

3. Conjoined manipulation. 

4. Abdominal palpation. 

5. Eectal touch. 

6. Yesico-rectal exploration. 

7. The speculum. 

8. The uterine probe. 

9. Tents. 

10. The endoscope. 

11. The exploring needle. 

12. The microscope. 

13. Auscultation and percussion. 

Anaesthesia. — This should not be resorted to unless there be 
some special indication for it. Should the patient be intracta- 
ble, delirious, or a malingerer ; should the investigation involve 
much severe pain ; or should there be some tonic spasm of the 
muscles as an element of the disease, as is the case in spurious 
pregnancy and phantom tumors, it affords an aid to diagnosis of 
great value, and should never be neglected. "When we are forced 
to examine a virgin who is very sensitive, and opposed to the 
investigation, it is sometimes advisable, for without, it a diagnosis 
is frequently not practicable.- 

The Vaginal Touch. — This, which will be the first explora- 
tive measure to which the examiner will resort, constitutes one 
of the most important at his command. It will reveal much or 
little, as it is practised slowly and thoughtfully, or hastily and as 
a matter of routine. In making it the index finger of either hand 
may be employed, and when it is desirable to reach as far up 
the pelvis as possible, the index and middle fingers may be used. 
During this examination the patient should be invariably laid 
upon the back, with the legs flexed and the buttocks very near 



CONJOINED MANIPULATION. 67 

the edge of the table. The observance of this position is of great 
importance, as the vaginal touch should in every case be com- 
bined with abdominal palpation, to which union the name of 
conjoined manipulation, or bi-manual palpation, has been ap- 
plied. 

The index finger of one hand being introduced into the vagina, 
the other fingers being flexed into the palm and the thumb laid 
upon them, passes directly to the cervix uteri, assuring the in- 
vestigator as it goes of the perviousness of the vaginal canal. 
Upon reaching the os, this part is carefully»examined with refer- 
ence to size, consistency of lips, and character of discharge ; a 
patulous os, with soft velvety sides covered by a glutinous secre- 
tion, admonishing him of the existence of inflammation of the os 
and cervical canal. The cervix should then be examined with 
reference to location, size, and density. This being done, the 
finger should be slid along its posterior surface into the recto- 
uterine space, and the presence there of any hardness or tumefac- 
tion noted. Should such be found, it will probably be due to 
one of these causes, retroflexion or retroversion of the uterus, 
uterine enlargement, a fibrous tumor, scybala in the rectum, inflam- 
matory products the result of peri-uterine cellulitis or peritonitis, 
a prolapsed ovary or ovarian tumor, or an hematocele. Should 
no tumor be discovered, but the line of resistance given to the 
finger be found to disappear at the vaginal junction with the 
uterus, it may be inferred with moderate certainty that at this 
point none of the above mentioned conditions exist. 

This space being explored, the finger should then be passed 
anteriorly, and swept upward and forward along the base of the 
bladder towards the symphysis pubis. Any hardness discovered 
here will probably be due to anteflexion or anteversion of the 
uterus, a fibrous tumor, stone in the bladder, uterine enlargement, 
hematocele, or cellulitis. 

The state of the ovaries should then be interrogated by lateral 
pressure, and the condition of the pelvic areolar tissue and walls 
by firm pressure in all directions. 

Conjoined Manipulation, or Bimanual Palpation. — As 
the preceding examination consists in touching organs above the 
pelvic roof for the most part, and which arc generally quite 



68 MEANS OF DIAGNOSIS. 

movable, it is evident that its results are diminished by ascent of 
these parts as they are pressed upon. To bring them more fully 
within the reach of the finger in the vagina, and to obviate their 
retreat, abdominal palpation should invariably be combined with 
the vaginal touch. While the latter is being performed by the 
index finger of one hand, the other hand should be placed on the 
abdomen, and by it the uterus be made to descend, so that even 
its upper parts may become accessible. This will enable the 
examiner to sweep the finger in the vagina over the posterior, 
anterior, and lateral surfaces of the organ, and detect the presence 
of any enlargement, sensitiveness, or abnormal growth there. 
Fig. 2 represents this. 

Fig. 2. 



Practice of conjoined manipulation. (Sims.) 

But not only should the walls of the uterus be thus explored; 
the volume, shape, sensitiveness, and regularity of surface of this 
organ, as well of the ovaries, the broad ligaments, anterior vagi- 
nal wall and bladder should likewise be ascertained by it. To 
accomplish -this, with reference to the uterus, let the vaginal finger 
be placed under it — anterior to the cervix if it be in normal posi- 
tion or anteflexed, posterior to it if it be retroflexed — and the 
organ will be distinctly felt resting between it and the fingers 
which depress the abdominal wall. By the same method the other 
parts mentioned should be examined. Bimanual manipulation is 



THE KECTAL TOUCH. 69 

of great importance ; indeed no examination can be considered 
complete without it. By a neglect of this seemingly trifling pre- 
caution I have known the existence of large tumors, and even 
of pregnancy quite advanced, entirely ignored. A short time 
ago a physician sent to me from a distance a case which he sup- 
posed to be one of prolapsus uteri, from the fact that the uterus 
was low in the pelvis, never suspecting for a moment the existence 
of two fibrous tumors, each the size of a foetal head, which weighed 
down the displaced organ. 

Abdominal Palpation. — The practice of bimanual palpation 
will have assured the investigator of the presence of any tumors 
which may exist in the pelvis. Should such have been disco- 
vered, a further examination will, of course, at once be entered 
upon to ascertain their size, shape, attachments, and contents. In 
this exploration both hands are employed externally, and by them 
firm pressure is made and the abdominal walls depressed, so that 
by grasping the masses their characters may be appreciated. 

The Eectal Touch. — Should anything have been discovered 
upon either uterine wall to make further light upon the state of 
these parts desirable, or should symptoms have presented them- 
selves which excite suspicion of the presence of some morbid 
growth, the index finger of one hand should be carried far up into 
the rectum, and if necessary to enable it to reach the upper portion 
of the posterior uterine wall, a tenaculum should be fixed in the 
outer surface of the cervix, and by gentle traction the organ drawn 
down. Generally, however, sufficient depression will be accom- 
plished by firm pressure over the hypogastrium with the other 
hand, the tips of the fingers pressing the uterus towards the floor 
of the pelvis ; or both of these means may be combined by bring- 
ing to our aid the hand of an assistant. They who have not 
employed this method systematically must have a faint idea of 
the great facility which it gives for exploration of the posterior 
wall and recto-uterine space. 

Should any substance lie in the recto- vaginal space, its charac- 
ter maybe accurately appreciated by what has been styled by Dr. 
Tilt the " double touch," which consists in introducing the index 
finger into the rectum and the thumb into the vagina, and then 



70 MEAXS OF DIAGNOSIS. 

approximating them. Or the index of one hand may be intro- 
duced into the vagina and that of the other into the rectum. 

Vesico-kectal Explokation. — This consists in passing a 
catheter or sound into the bladder, and pressing it towards the 
index finger in the vagina. Its scope is not extensive, but for 
some purposes no other method answers the same end, as for 
example for the following : — 

Appreciating the size of uterus in very fat women; 

Detecting absence of the uterus; 

Differentiating inversion from polypus. 
The only difference between this method and conjoined mani- 
pulation consists in the attempt to grasp the uterus between the 
finger and sound, instead of between the fingers of the two hands. 

The Speculum. — This is by no means our most valuable diag- 
nostic resource. Too great a reliance upon it as such is calculated 
to diminish the physician's powers in arriving at a correct con- 
clusion in obscure cases. Unquestionably the greatest benefits 
derived from the speculum demonstrate themselves in the thera- 
peutic department of the art. As a diagnostic means it is inferior to 
the vaginal and rectal touch combined with abdominal palpation, 
and chiefly aids us in this field by opening the way to the proper 
use of the uterine probe, which constitutes one of the most relia- 
ble methods at our command for appreciating the condition of the 
cavity of the uterus. 

All vaginal specula may be classified under two heads, cylin- 
drical and valvular. Of the first variety cylinders of metal, 
porcelain, ivory and wood are in general use. None of these 

Fig. 3. 




Fergusson's speculum. 

compare in elegance, cleanliness and utility with that of Dr. 
Fergusson, of London, which consists of a tube of glass coated 
with quicksilver, and covered by India-rubber, which is tho- 
roughly varnished. This instrument is represented in Fig. 3. 



THE SPECULUM. 71 

Objections which attach to all cylindrical instruments are the 
following: to suit all cases they must be from five to six inches 
long, which renders probing the uterus through them impossible, 
and prevents applications from being carried to the fundus ; it is 
not possible to examine through them by touch ; in anteversion it 
is difficult to get the cervix into the field. The instrument repre- 
sented by Fig. 4 obviates many of these difficulties by accommo- 
dating itself to the length of every vagina, so that the shoulders 
come just between the labia. 

Fig. 4. 




' T/£AMM/V=CO. 

Thomas's telescopic speculum. 

It consists of two thin metallic tubes, one of which slides within 
the other. To the inner tube is attached, at the mouth, wings 
which sustain the labia, and the outer tube ends in a tip which 
is either straight or curved. It is called the " telescopic spe- 
culum," from its mechanism, and measures, when not extended, 
along its shorter side two and a half inches, along the opposite, 
three. When extended, it is as long as the ordinary cylindrical 
specula. On both surfaces, upper and lower, are two fenestra?, 
which admit of elevating or depressing the probe in cases where 
flexion or version exists, and its handle must be much lowered. 
A downward curve may with advantage be given to the longer 
lip. This curve looks at first very odd and useless ; but upon 
experiment it will be found to answer a very useful purpose. 
In cases where the uterus is normal in positiou it will not depress 
the cervix too much, while by turning it up when this part lies 
imbedded in the hollow of the sacrum the examiner will be en- 
abled to lift it and engage it in the field of the speculum. When 
fully introduced the wings at the mouth of the instrument support 
the labia, and thus no superfluous portion extends bej'ond the 
vulva. 

A rougher instrument Avhich I have used with great satisfaction 
is one made of thin sheet iron, measuring on both faces throe and 



72 MEANS OF DIAGNOSIS. 

a half inches (Fig. 5). The only objection to this is that in cer- 
tain rare cases it will prove too short to reach an elevated cervix. 
Through it the "uterus may be readily probed to the fundus. 

Fie. 5. 




Short cylindrical speculum. 

Of valvular specula the bivalve of Ricord, the trivalve of 
Segalas and the quadrivalve of Charriere have long been popular. 
No instrument of this variety with which I am acquainted equals 
in beauty and utility that of M. Cusco. It is compact, easily 
introduced, and shows the cervix very clearly. They all, how- 
ever, present these great disadvantages. It is difficult to avoid 
prolapse of the vaginal walls between their branches, and in re- 
moving the instrument they are liable to be painfully pinched. 
If, upon introducing and expanding their branches, the os uteri is 
exposed, all goes well ; but if it is not in the field, these instru- 
ments are awkward and unwieldy in overcoming the difficulty ; 
indeed, in many cases, the speculum must be withdrawn and re- 
introduced to accomplish the result. They have, however, one 
great advantage over the cylindrical specula, namely, their intro- 
duction is attended by much less pain. Should the case be one 
of a multipara, the cylinder may be introduced without pain, but 
in a nullipara, or virgin, it is often produced. 

Like the cylindrical, the valvular specula in general use do not 
admit, as a rule, of probing the uterus and making applications to 
the fundus. I do not deny that in some cases it is possible, nor 
that by perseverance a skilful operator niay succeed in effecting 
these objects in many instances, but it is usually so difficult that 
the general practitioner will not find such specula available for 
these ends. 

Sims's speculum, Fig. 6, which is in reality a bivalve, obviates 
all these difficulties in the most complete and satisfactory manner. 
In exposing the uterus it develops a principle not brought into 
action by any other variety, the dilatation of the vaginal canal by 



THE SPECULUM 



73 



air, which enters on account of the position 
of the patient and gravitation of the pelvic and 
abdominal viscera. I have stated that this 
instrument is a bivalve speculum ; the upper 
valve is constituted by the blade of the 

Fig. 7. 



S. TIEMAHN-CO. 




Sims's depressor. 

speculum itself and the lower by the de- 
pressor, represented in Fig. 7, which acts 
upon the anterior wall. 

The facility which Sims's instrument gives 
for exploration and treatment is very great ; 
so great, I think, that the practitioner devot- Sims's speculum, 

ing himself to Gynecology who does not avail 
himself of it, loses as great an advantage as the auscultator would 
forego in not bringing to his aid the double stethoscope of Camman. 
But, unfortunately, this instrument presents such disadvantages 
that it can never come into general use. In the hands of special- 
ists and obstetric surgeons it will always fill a large place, but in 
general practice it will not do so. It cannot be employed without 
an assistant, and not only so, a skilled assistant is necessary for it 
to be of real value. This fact has incited many to alter Dr Sims's 
original model so as to combine its advantages in instruments 
free from the objections which have been mentioned. Three of 
these I shall present as attaining this end, one by Dr. Emmet, and 
two by myself. 

When by Sims's speculum the posterior vaginal wall is lifted, 
the anterior must be depressed by an instrument held in the other 
hand. This occupies .both hands, and the operator is bereft of 
power to proceed. The object of the alteration is to liberate one 
hand in order that the further steps of the examination may be 
proceeded with. Dr. Emmet's speculum, Fig. 8, does this by a 
piece of steel like the blade of a pair of forceps clasping the 
buttocks and exerting an elevating power upon the portion of 



74 



MEANS OF DIAGNOSIS. 




Emmet's speculum. 



Fig. 9. 



Fi g- 8 - the instrument within the vagina, by 

action of a screw at a. When this 
is adjusted it keeps its place. One 
hand then depresses the anterior 
wall of the vagina, and the other is 
free. Should it be necessary to alter 
the shape of the sacral blade to suit 
that of the buttock, this may be ac- 
complished by a screw at 5, and if 
it be desired to elevate the upper 
lateral wall of the vagina and right 
labium, a screw at c accomplishes it. 

The instrument represented in Fig. 9 clasps the sacrum, one 
blade, a, the speculum itself, being placed within the vagina, and 

the other, &, on the outer surface of 
the sacrum. Their approximation 
by the left hand elevates the poste- 
rior vaginal wall, and the handle is 
held by one hand. The anterior wall 
is then depressed by the depressor 
c, and thus one hand is free. This 
instrument appears complicated in a 
diagram, but in reality it is by no 
means so. For a long time I em- 
ployed it without the sacral piece as 
represented in Fig. 10. Some even 
now prefer it thus, though the fa- 
tigue which it causes to the left arm 
in lifting the posterior vaginal wall 
and perineum, constitutes an objection to it. 

The same principle I have developed by an alteration in 
Cusco's speculum, as represented in Fig. 11. In its use, of course, 
the woman lies on the side. The blade b is very shallow, and is 
split by a long fenestra, which admits of depression of the handle 
of the probe, so that it may be passed to the fundus uteri. These 
instruments are inferior to that of Sims in almost every respect. 
They possess the single advantage of being available for general 
practice. 




Thomas's modification of Sims's 
speculum. 



THE SPECULUM. 



75 



Fig. 10. 



Fig. 11. 





Sims's speculum with fixed 
depressor. 



TJEMANN-CQ. 

Cusco's speculum modified. 

Method of Introducing Valvular and Cylin- 
drical Specula. — The patient being placed 
in position on the back, as already ex- 
plained, and the speculum, probe, and 
whatever other instruments are to be em- 
ployed, laid in a basin of warm water at 
the bedside, the physician seats himself in 
a chair, or if a low bed be used instead of 
a table, kneels, or sits upon a stool. The finger having been 
thoroughly lubricated with soap is passed up, and the location of 
the cervix ascertained. The speculum, similarly lubricated, is 
then passed in this way ; if the cylindrical instrument be used, 
the perineum is depressed by its tip, and it is very slowly and 
gently inserted and carried to the cervix — should one of the 
valvular varieties be employed, it is inserted closed, and expanded 
after reaching the cervix. 

Introduction of Sims's Speculum and its Varieties. — In this method 
of examination the element which, controls success is not the use 
of the instrument, but the position of the patient. If the posi- 
tion recommended by Sims be attained, exposure of the cervix 
will be easy ; if a similar, but not identical attitude be substituted, 
the examination will prove a failure. 

The object of the position is to allow the abdominal viscera 
and walls to gravitate, so as to draw the anterior wall of the 
vagina forward, in a direction opposite to that impressed upon 
the posterior wall by the speculum. To accomplish this the pa- 



76 



MEANS OF DIAGNOSIS. 



tient must not be on her back, nor yet on her side, but in a posi- 
tion between the two. This is badly represented in Fig. 12. The 




Fig. 13. 



Nurse holding Sims's speculum. (Sims.) 

left arm must be drawn behind her so as to let her rest on the left 
side of the chest, and the right leg be so flexed as to let the right 
knee lie just above the left. 

When the patient is arranged, the correctness of the posture 

may be tested by noting that the 
lower trochanter is not just oppo- 
site the upper, but nearer to the 
examiner by two or three inches. 
I am thus particular in describing 
this position, first, because it is 
difficult for one unaccustomed to 
its employment, to place his pa- 
tient properly in it ; and, second, 
because upon its perfect attain- 
ment depends the successful use 
of Sims's speculum. This being 
done, the speculum, held as repre- 
sented in Fig. 13, is introduced, 
the posterior vaginal wall elevated 
Position for introduction (Sims). by it and the anterior depressed 




THE UTERINE SOUND AND PROBE. 77 

by the depressor, Fig. 7, held in the other hand, or by the me- 
chanical depressors represented in Figures 9 and 10. 

The Uterine Sound and Probe. — This most valuable diag- 
nostic means was published to the world about the year 1843. 
The credit of its discovery is claimed for Simpson, of Edinburgh, 
Huguier, of Paris, and Kiwisch, of Prague. These practitioners 
simultaneously revived an old method of diagnosis which had 
been described in modern times by Lair,' but had been allowed to 
fall into oblivion. It matters little to which of them belongs the 
credit of having been the first to conceive the idea of the regene- 
ration, to Dr. Simpson certainly belongs that of having forced it 
upon the attention of the profession and established its value by 
clinical evidence. 

The instruments in general use are those of Simpson, Yalleix, 
Huguier, and Kiwisch, which resemble each other closely in 
principle, each consisting of a stiff metal rod divided into half 
inches and bent so as to pass in the axis of the healthy uterus. 



Fig. 14. 





<2 



Sounds of Valleix and Kiwisch. 

The method of their introduction is this : the index finger of one 
hand being introduced into the vagina and placed against the cer- 
vix, the sound is by the other slid upon its palmar surface to the 
os, passed into it, and by depression of the handle gently advanced 
to the fundus. If the uterus is in its normal position, and the 
sound be used by a skilful hand, the operation is not difficult. 
But it is not healthy uteri which we are generally called upon to 

1 Samuel Lair, "Nouvelle methode de traitement des ulceres, ulcerations et en- 
gorgement de l'uterus," 1828. 



78 MEANS OF DIAGNOSIS. 

explore. If the organ be displaced, the difficulties and dangers 
attending its employment are considerable, as may be judged of 
from the following quotations: — 

Becquerel 1 says, " But its employment is attended with such 
difficulty that it requires all the skill of an adroit and experienced 
practitioner, and we dread seeing it popularized among young 
physicians of little skill and experience." Konat 2 declares that 
" on account of the accidents which sounding may excite, it should 
only be resorted to with great caution and in those cases where 
its necessity is clearly shown." Scanzoni 3 candidly acknowledges 
that, "in the first place, the uterine sound is by no means so 
harmless as has been asserted," and then goes on to sum up the 
evils which may result from it. But I will not quote more ; this 
suffices to show how the difficulties and dangers to which I have 
alluded are esteemed by some of the best authorities of our day- 

The facts which may be ascertained by the probe are these : — 

1. The capacity of the uterus. 

2. The existence of growths within it. 

3. Deviations of the course of its canal. 

4. Differentiation of these from uterine tumors. 

5. The existence of endometritis. 

The great importance of these facts with reference to diagnosis 
is evident, and one would suppose that an instrument revealing so 
much would be universally employed. Such, however, is not by 
any means the case. By adepts it is commonly resorted to, but 
in general practice will be found many, indeed a majority, who 
do not employ it from fear of its results, the difficulty of its intro- 
duction, and uncertainty as to its revelations. It is my opinion 
that no case of uterine disease should be regarded as fully investi- 
gated unless the cavity of the uterus be probed. Of course there 
are, in some cases, contra-indications to such a procedure, but 
where none exists it should be considered as essential to a tho- 
rough examination. % 

Dr. Sims has furnished us with a new instrument and method 
for probing this organ, which acts upon an essentially different 
principle from that formerly employed, and makes the investiga- 

1 Maladies de l'uterus. 2 Maladies de l'uterus. 

3 Diseases of Females, Am. ed. 






THE UTERINE SOUND AND PROBE. 



79 



tion so simple and void of danger that I strongly recommend its 
adoption. In my own practice I use it in almost every case 
which I examine, and never have I done injury to a patient except 
in a few rare cases where miscarriage was produced, no suspicion 
of pregnancy being entertained. 

Figure 17 represents the sounds of Simpson and Sims, for the 
purpose of contrasting them. The first is a strong, unyielding 
staff, composed of German silver, and as large as a No. 3 catheter. 

Fig. 17. 




Sounds of Simpson and Sims compared. (Sims.) 



The second is not a sound, but a probe, only a little larger than 
the ordinary surgical probe, composed of pure silver or copper, 
and perfectly pliable. 

Dr. Sims has gradually decreased the size of the probe, so that 



80 MEANS OF DIAGNOSIS. 

that which is very commonly employed in New York, at present, 
is no larger than represented in Fig. 18. 

Fig. 18. 




Sims's probe, smallest size. 

Method of Probing the Uterus. — While the woman lies on her 
back, the examiner, by vaginal touch, carefully ascertains the posi- 
tion of the uterus, by passing his finger, first into the fornix 
vaginas over its posterior face, and then along the base of the 
bladder, over its anterior wall. This gives him a definite idea of 
the direction of the canal along which he is to pass his probe, and 
without it he should never essay the procedure. The speculum 
is then introduced, the patient preserving the dorsal decubitus 
if a short cylindrical instrument be employed, and being turned 
on the left side if Sims's or one of its varieties be used. The 
examiner then takes the probe, and with his fingers gives it the 
exact curve which he supposes the uterine canal to have, and 
gently passes it in. Should he fail, he alters the curve slightly, 
and makes another attempt until he succeeds, which will be very 
soon if he has used this method so often as to have given himself 
experience. Every effort at introduction is made as cautiously 
as if the probe were passing into the larynx instead of the womb, 
and no force whatever is exerted. Success is attained by pro- 
perly curving the probe, and by that alone. Sometimes the curve 
given to it must be the arc of a small circle, at others a sharp 
angle, sometimes the instrument is left perfectly straight ; in fact 
every conceivable shape may be given it. In a certain set of rare 
cases, even a spiral twist is required. 

Thus employed, the uterine probe becomes a means of verify- 
ing a diagnosis which has been made by touch, and is certainly 



TENTS. 81 

safe, easy of introduction, and painless. It may be employed in 
all cases, except pregnancy, doing no injury even in metritis, so 
gentle is its entrance into the inflamed cavity. 

Having passed it, no one can dispute the fact that it performs 
the chief functions of the sound, proclaiming the course, length, 
and capacity of the uterine canal. 

Tents. — Before the time of Eecamier, the cavity of the uterus 
was a space entirely closed to investigation and local therapeutics, 
unless the os were largely dilated by disease. He not only aspired 
to an accurate knowledge of its affections, but boldly applied his 
remedies directly to the diseased surface ; and in cases of intra- 
uterine granulations, scraped off the diseased mucous coat with the 
curette. Even to him, however, the diagnosis of diseases within 
the cavity when the os was closed was an impossibility, and for 
the means of combating this difficulty we are again indebted to 
Dr. Simpson, who, in 1849, placed the use of sponge tents among 
the most important of our resources for diagnosis. 

The object for which they are employed is the dilatation of the 
cervical canal in order that the cavity of the body may be exa- 
mined by touch, or sight, and that treatment may be applied in 
cases of polypus, granulations, fibrous tumors, hydatids, removal 
of the products of conception, &c. 

A variety of substances have been recommended for the manu- 
facture of tents, only two of which have come into general use, 
compressed sponge and the laminaria digitata, or sea tangle. 

Mode of Preparing Sponge Tents. — The sponge employed should 
be of good quality, though not of the finest texture, which is not 
sufficiently unyielding to overcome the resistance of the cervix as 
it expands. It should be thoroughly cleansed by boiling in water 
rendered alkaline by bicarbonate of soda, and all adhering particles 
of earthy matter carefully removed. This being done, it should 
be cut into conical pieces, varying in bulk from that of the little 
finger to that of an egg^ and in length from two inches to three and 
a half. Small tents, which are to be employed only for opening 
the cervical canal, need not be made longer than two inches, but 
those employed for complete dilatation in cases of polypus and 
fibrous tumors should measure three or even three and a half. 
As Dr. Noeggerath has advised, each piece should then be soaked 



82 MEANS OF DIAGNOSIS. 

in a weak solution of carbolic acid, which destroys to a great 
extent the fetid odor developing itself after the tent has been 
kept in the uterus for some hours. The sponges are then satu- 
rated with mucilage of gum acacia, and a sharp wire being passed 
through the centre of one piece, it is tightly wrapped with strong- 
cord from the apex to the base. The wire is then removed and 
the tent left to dry. As soon as it is thoroughly dried the cord 
is removed, the asperities of the tent pared off with a sharp knife, 
and a piece of soft cord or tape tied to the extremity, if the 
practitioner desires, to facilitate its removal. 

Fig. 19. 




A sponge tent. 

In Europe they are prepared by machinery, and are far supe- 
rior to those made as above described. 

To prevent contact between the sponge, loaded as it is with 
organic elements, and the mucous lining of the uterus a variety 
of expedients have been resorted to, such as coating them with 
tallow, glue, wax, &c. A very ingenious plan for accomplishing 
this has been recently suggested by Prof. J. C. Nott, 1 of Balti- 
more, who speaks highly of it from extensive experience. 

The tent prepared as above directed and made smooth by sand- 
paper is covered by goldbeater's skin, which is brushed over with 
a paste which is prepared after the following formula. Take of 
acetate of lead and sulphate of alum each 3iij and dissolve in 
water. Take of gum Arabic 3v and dissolve in one pint of water. 
Mix in a dish a quarter of a pound of wheat flour with the gum 
water cold, till pasty in consistence. Put the dish on the fire and 
pour into it the mixture of alum and lead. Shake well, and 
take it off the fire when it shows signs of ebullition. Let the 

1 Richmond Med. Journ., July, 1867. 



TENTS. 83 

whole cool, and the paste is made; if too thick, add to it some gum 
water till of proper consistence. The goldbeater's skin, cut of the 
length of the tent, is coated with this paste and the tent rolled in 
it until it is enveloped five or six times. It is then dried, after 
which several rows of perforations are made from end to end of 
the tent, with a pocket knife, to admit fluids. They are now as 
smooth as cigars, very firm, and can be introduced very easily. In 
introduction and removal the skin protects the uterus perfectly. 

Preparation of Sea Tangle Tents. — In 1862 Dr. Sloan, of Ayr, 
Scotland, recommended the use of this substance for dilating the 
cervix uteri. The laminaria is an aquatic plant found upon 
various parts of the Atlantic coast of Europe and America. 
That found in the Bay of Fundy, I am informed by Messrs. Tie- 
man & Co., is far superior to any other with which they have 
experimented. This plant, when saturated with moisture, swells 
to three times the bulk which it has when thoroughly dried. In 
its moist state a long piece of it is perforated at both extremities, 
in order that it may be hung up and allowed to dry, a weight 
being attached to the lower end so as to stretch it and make it 
straight. When dry, this is cut into pieces from two to two and 
a half inches long and made perfectly smooth and round by a 
knife, a piece of glass, or sandpaper. Ti email & Co. prepare them 
very beautifully by turning in a lathe. 

Dr. Greenhalgh, of London, has improved these tents by having 
them perforated from one extremity to the other, so as to make 
them tubular instead of solid. Thus prepared they will dilate 
much more rapidly and efficiently. One of Dr. Greenhalgh's tents 
is represented in Fig. 20. 

Fig. 20. 




A sea tangle tent. 

The advantages of these tents over those made of sponge con- 
sist in their creating no fetor, and presenting no animal matter 
for absorption. Their disadvantages are their requiring a longer 



84 



MEANS OF DIAGNOSIS, 



time for expansion, their being kept in the cervix with greater 
difficulty, and offering a harder substance to the walls of the 
cavity of the uterus. My own experience with them leads me to 
believe that from their decided inferiority to tents made of sponge, 
and to the fact that the latter are being rapidly freed from their 
disadvantages, sea tangle tents will in a few years disappear from 
practice. 

Mode of Introducing Tents. — If the uterus be low in the pelvis 
and its neck dilated, a tent may be held in the bite of any pair 
of uterine dressing-forceps and slipped in without the speculum, 
the woman lying on the back. In ordinary cases they should be 
introduced through, the short cylindrical, or one of the varieties 
of Sims's speculum. The introduction is most easily accomplished 
with the last in all cases, and in some it can only be effected with 
it. The uterus being fixed and held by the tenaculum, Fig. 21, 

Fig. 21. 



& r//ZM/i//d CO. 



Tenaculum for fixing the uterus. 

and the tent grasped by a pair of mouse-tooth forceps, is directed 
in coincidence with the axis of the uterus, as ascertained by the 
probe, and gently pushed through the cervix, as represented in 
Fig. 22. 

Fig. 22. 




Introduction of a tent. (Sims ) 



THE EXPLORING NEEDLE. 85 

Should its retention be doubtful, a mass of cotton is then packed 
against it so as to keep it in place, and the woman is directed to 
keep quiet upon her bed until it is removed. 

Its removal is accomplished, through the speculum, by the 
same forceps by which it is introduced, in from twelve to twenty- 
four hours. 

Dangers. — There is always danger in dilating the cervix by 
tents, though it is by no means so great as to make one hesitate 
in employing them. In a case which I saw in consultation with 
Dr. Edward Parsons I employed two tents in succession, and, in 
about twenty-four hours after removal of the second, tetanus 
developed itself, which proved fatal. In one case, in the practice 
of another physician, I have seen death result from peritonitis 
after their use ; and in three others have known peri-uterine cel- 
lulitis thus produced. 

The Endoscope. — This instrument consists merely of a long 
cylindrical tube of metal, through which, by a very strong light, 
we are able to see for a considerable distance down narrow canals. 
It has been employed for visual examination of the deepest por- 
tions of the urethra, and by means of reflecting mirrors even 
hollow viscera, as the bladder, have been explored. I have not 
experimented with it sufficiently to determine what can be accom- 
plished by it for the diagnosis of uterine disorders, but have satis- 
fied myself that as far as the os internum it may be used with slight 
advantage. I have employed a straight tube only, and hence have 
not been able to explore the body of the uterus, but varieties which 
are bent and supplied with mirrors have been used. If the cervix 
is dilated, the endoscope may be at once introduced after the part 
has been carefully cleansed of mucus. If it be closed, it will be 
necessary to dilate it with a tent, and to wash away all blood ooz- 
ing forth in consequence with ice water, which will check further 
flow. Then the tube is carried up through the speculum to the 
requisite extent, and the light to be employed thrown through it. 
The endoscope will, probably, never prove of great value in this 
field. 

The Exploring Needle. — By means of a long delicate needle, 
or very narrow tube, constituting a canula for a trocar the size of 
a knitting-needle, the contents and characters of tumors in the 



80 MEANS OF DIAGNOSIS. 

pelvis may be ascertained. These instruments are not employed 
in treating cysts, but are required only to remove so much fluid 
as to announce the character of the contents of the tumor. Some- 
times a tumor, supposed to be solid and irremediable, is thus 
proved amenable to treatment by incision or the trocar. 

The Microscope. — The microscope will sometimes prove use- 
ful as an aid in diagnosis in determining the malignant nature of 
certain morbid growths, the character of products of inflamma- 
tion, the connection of intra-uterine growths with the results of 
conception, the purulent nature of uterine leucorrhcea, &c. 

Auscultation and Percussion. — The important assistance of 
auscultation and percussion in mapping out the size of tumors, 
determining pregnancy, differentiating this from ovarian cysts, 
&c, is so evident as merely to require a passing mention. 

RECAPITULATION OF MEANS FOR EXPLORING PELVIC VISCERA AND 

TISSUES. 

1st. Vagina and Cervix — 

Yaginal touch ; 

Sight, through the speculum. 
2c?. Outer Surface of Uterus — 

Yaginal and rectal touch, while the organ is brought 
within reach by hypogastric pressure or the tena- 
culum; 

Conjoined manipulation ; 

Vesico-rectal exploration. 
3'i. Cavity of Cervix and Body — 

Tents, followed by introduction of finger ; 

The uterine probe ; 

The endoscope. 
Azth. The Ovaries, Broad Ligaments, Pelvic Peritoneum, and Pel- 
vic Areolar Tissue — 

Vaginal touch ; 

Eectal touch ; 

Conjoined manipulation ; 

Abdominal palpation ; 

Auscultation and percussion ; 

The exploring needle. 



CHAPTEE IY. 



DISEASES OF THE VULVA. 



Normal Anatomy. — The vulva is the elliptical opening which 
exists at the distal extremity of the vagina, and comprises the 
mons veneris, labia majora and minora, clitoris, meatus urina- 
rius, vestibule, fossa navicularis, fourchette, and hymen. 

Labia Majora. — From the mons veneris, which consists of 
adipose tissue covered by skin in which exist numerous hair bulbs, 
two folds of integument pass downwards to unite at the fourchette. 
These are called the labia majora. Externally they are covered 
by skin, which contains scattered hair bulbs, but on their inner 
surfaces their covering is mucous membrane, which is studded 
with sebaceous follicles, the secretion of which is unctuous and 
semi-solid. Within, the labia are filled with adipose tissue, a 
portion of which is inclosed in sacs of which one arises from each 
external abdominal ring and extends downwards towards the 
fourchette. 

The Clitoris. — Beneath the superior commissure of the labia juts 
forward a little erectile organ, which is analogous to the penis of 
the male, and receives the name of clitoris. It is covered by 
mucous membrane, consists of erectile tissue, and arises by two 
rami, one of which is attached to each ramus of the pubis. Like 
the male penis, this little organ is provided with a prepuce and 
frenum. 

Labia Minora. — These consist of two folds which, arising at the 
clitoris, pass downwards and disappear about half way between the 
two commissures. Like the clitoris, they are formed of erectile 
tissue covered over by mucous membrane, and an attentive exa- 
mination discovers upon their surfaces a large number of glands 
which secrete a sebaceous material. 



88 DISEASES OF THE VULVA. 

The Fossa Navicularis and Vestibule are merely spaces inter- 
vening; the first, between the perineum and vagina; the second, 
between the meatus and clitoris. They are both covered by 
mucous membrane, and the latter is studded with follicles. 

The Hymen is a thin veil consisting of a double fold of mucous 
membrane, which in part closes the ostium vaginas. When rup- 
tured its remains contract and form little tubercles on the walls of 
the vagina, which receive the name of carunculse myrtiformes. 

Passing over the clitoris, to which it is attached, and running 
downwards on each side of the vulva so as in part to cover the 
bulbi vestibuli, will be seen a muscle, the sphincter vaginae. 
Some of its fibres pass down to the perineum to inosculate with 
the sphincter ani, with which it continues as a figure of 8, but 
the greater portion decussate to the surrounding areolar tissue. 

Vulvitis. 

Definition. — Vulvitis is the name applied to inflammation of the 
mucous membrane lining the vulva. Affecting all of this struc- 
ture, its surface covered by epithelium and the glands imbedded 
in it, the inflammatory action sometimes extends through the 
submucous tissue into the proper structure of the parts under- 
lying it, creating tumefaction, pain, and sometimes even suppura- 
tion. 

Varieties. — Authorities differ with regard to the classification 
of its varieties. 

That which appears most appropriate is the following : — 
Purulent vulvitis ; 
Follicular vulvitis ; 
Gangrenous vulvitis. 

Purulent Vulvitis. 

This variety of the affection may be either of non-specific form, 
or a true gonorrhoea of the vulva. The former is in many respects 
analogous to ulcerative stomatitis, while the latter resembles very 
closely specific inflammation in other mucous membranes of the 
body. 



PURULENT VULVITIS. 89 

Causes. — It" may result from 
"Vaginitis ; 

"Want of cleanliness ; 
Injury; 

Eruptive disorders ; 
Onanism ; 
Chemical irritants. 

Symptoms. — The parts are red, swollen, hot, and at first dry. 
Then a free flow of pus takes place which bathes the whole surface 
and stains the linen of a yellow hue. In addition to these signs 
of active inflammation superficial ulcers will be found scattered 
over the parts affected and in rare cases patches of diphtheritic 
membrane will be seen adhering to them. At times the meatus 
urinarius becomes affected, and painful micturition with scalding 
and heat is complained of. At others the most intense pruritus 
affects the vulva, and the patient, in endeavoring to obtain relief, 
may contract the habit of masturbation. Should the inflamma- 
tion extend to the vagina, the symptoms of vaginitis will also show 
themselves, and by a similar extension to the bladder those of 
cystitis may develop. In severe cases febrile action, with thirst, 
heat of skin, and general discomfort is present, but not usually. 

Course and Termination. — Even without treatment it is probable 
that the affection would always be recovered from in time ; but 
it would run a lengthy and tedious course, and perhaps give rise 
to complications which would be productive of greater evil than 
the original disorder. When properly treated, it generally runs 
a rapid course and is readily cured. 

Treatment. — If inflammatory action is excessive, the patient 
should be kept in bed, upon low diet, and the bowels be freely 
acted upon by saline cathartics. Cooling and emollient applica- 
tions should be made constantly to the inflamed part, and clean- 
liness scrupulously observed. The patient should be directed to 
bathe the vulva freely with warm water three or four times daily, 
and a warm poultice of powdered linseed, slippery elm, or grated 
potato applied. To the poultices may be added with advantage 
acetate of lead and tincture or powder of opium. 

As soon as the acute action has subsided, the lead and opium 
wash should be kept in contact with the parts, by dossils of lint 
soaked in it, and placed between the labia. It is thus composed : — 



90 DISEASES OF THE VULVA. 

R.-Tr. opii, gij. 

Plumbi acetat. 3J. 
Aquae, Oj. — M. 

At a still later period the diseased surface should be painted 
over several times a day with equal parts of solution of persul- 
phate of iron and glycerine. Should the disorder not be entirely 
eradicated by this treatment, the vulva may be painted over once 
in every forty- eight hours with a solution of nitrate of silver, ten 
grains to the ounce of water, and kept constantly powdered with 
lycopodium, bismuth, or starch, until recovery is complete. 

Follicular Vulvitis. 

Definition and Synonymes. — It has been already stated that in 
the mucous membrane lining the vulva, more especially in that 
covering the labia majora, labia minora, and vestibule, are nu- 
merous follicles. Presenting themselves as solitary glands, they 
are classified under the following three heads — muciparous, seba- 
ceous, and piliferous. In ordinary purulent vulvitis, these, as 
component parts of the diseased membrane, are implicated in the 
morbid action. Sometimes, however, they alone are affected by 
disease, when the name of follicular vulvitis or vulvar folliculitis 
has been applied to the condition. Any or all the varieties of 
glands just mentioned may be diseased, and authors have given 
special names to the varieties, so that a list which would com- 
prise them all would be a long one. As an example may be 
mentioned papillary, pruriginous, erythematous, sebaceous, granu- 
lar vulvitis, &c. 

We may avoid tediousness of detail, and at the same time run 
no risk of being led into error, by classing all forms of inflamma- 
tion affecting the solitary glands of the vulva under the head of 
follicular vulvitis ; provided that we bear in mind that all the 
varieties of glands may be simultaneously affected, or that one set 
alone may be diseased, the others remaining healthy. 

Causes. — This form of vulvitis may be induced by the follow- 
ing influences : — 

Pregnancy ; 

Keglect of cleanliness ; 

Vaginitis ; 

Exanthemata ; 

Eruptions on the vulva. 



FOLLICULAR VULVITIS, 



91 



Symptoms. — There are burning, itching, and heat in the vulva, 
with increase of glandular secretion. At times the secretion be- 
comes excessively offensive and irritating in character. The 
urethra frequently becomes inflamed at its vulvar extremity, and 
scalding in the passage of urine results. The vulva may become 
so sensitive to touch, that efforts at sexual intercourse may excite 
vaginismus, which thus constitutes a symptom of the disease. 

Physical Signs. — Should the muciparous follicles be chiefly 
affected, the mucous membrane of the vulva is intensely red in 
spots or patches, which are slightly elevated. These are most 
commonly found on the edges of the lower vaginal ruga3, the 



Fig. 23. 




Follicular vulvitis. (Huguier.) 

nymphse, and carunculas. They sometimes resemble the swollen 
villi upon the tongue, and bleed upon slight irritation. 

Should the disease have affected chiefly the sebaceous and pi- 
liferous glands, little red, rounded papillae will be found on the 
surfaces of the labia majora and minora, and the base of the pre- 
puce of the clitoris. After a while a drop of pus will appear in 
the apex of each, which is soon discharged, and the distended 



92 DISEASES OF THE VULVA. 

follicle shrivels. Beneath the labia minora a semi-fluid mass of 
offensive secretion will generally be found, which will, if not 
carefully removed, conceal the follicles underlying it. 

Course and Duration. — If this disorder occur during pregnancy, 
it may disappear at its conclusion. If not, and it be not appro- 
priately treated, it may continue for an unlimited time and result 
in urethritis, not only in the patient, but in her husband. This 
fact should be especially recollected, for a suspicion of want of 
chastity may be excited in the mind of the husband, and serious 
domestic difficulty result. 

Treatment. — Follicular vulvitis should be treated upon the 
same principles as the purulent form, by repeated ablution, warm 
poultices, sedative washes, and astringents, especially the per- 
sulphate of iron and nitrate of silver. Dr. Oldham, who was one 
of the first to enlighten the profession in regard to this affection, 
placed great confidence in the following prescription : — 

R. — Acidi hydrocyanici dil. ^ij. 
Plumbi diacetatis, 9j. 

Olei cacao, ^ij. — M. 

Apply after washing the parts with cold water. 

Gangrenous Vulvitis. 

Definition and Synonymes. — This singular disease, which is in 
many of its attributes akin to the cancrum oris of children, has 
been synonymously described under the names of noma, carbuncle 
of the genitals, gangrene of the vulva, &c. It is fortunately 
a very rare affection, as it commonly proceeds to a fatal issue. 

Pathology. — A survey of the predisposing causes, none which 
are exciting being known, will convince the reader that this form 
of vulvitis, unlike the other affections of the genital organs which 
we have just considered, is dependent upon a depraved blood 
state, one somewhat similar to that which produces like results 
in the mouth and fauces in continued fevers, scarlatina, &c. 

Causes. — The constitutional states which are known to result 
in it are — 

Peculiar epidemics of puerperal fever ; 
An unknown epidemic influence ; 
Scarlatina, measles, and continued fever. 



GANGRENOUS VULVITIS. 93 

The affection has sometimes been observed to take on an epi- 
demic character like similar disorders in the throat and mouth. 

Symptoms. — Yelpeau 1 describes these in the following graphic 
manner: "A patch or vesicle of grayish, reddish, or blackish 
hne, which ulcerates and soon becomes depressed in the midst of 
swollen and indurated tissues which are of a red color, forms gene- 
rally the point of departure. From this moment the gangrene 
advances step by step ; mortification affects the parts; an ichor- 
ous, fetid, nauseating fluid bathes the labia majora; separation of 
the gangrenous patches takes place slowly, and instead of limiting 
itself the process of destruction continues sometimes to extend 
until the death of the patient. The vital forces rapidly break 
down, and many children would die of this dreadful affection if 
art did not promptly interpose." 

A swollen, purplish, and ©edematous state of the labia, ac- 
companied by grave constitutional signs, in a child exposed to 
any of the predisposing causes mentioned, would at once excite 
the suspicion of one at all familiar, even in theory only, with the 
existence of this malady. The only disease with which it would 
probably be confounded is diphtheria of the vulva, and this would 
readily be differentiated by the patches of false membrane which 
would cover the mucous lining of the part. 

Treatment. — As soon as the nature of the disease is ascertained, 
both constitutional and local treatment should be promptly and 
energetically established. The patient should be placed in bed, 
in an apartment supplied by the purest air, and all depressing in- 
fluences should be removed from her. The most nutritious food 
and wine or other stimulants should be administered, and the 
forces sustained by quinine and muriated tr. of iron in large and 
repeated doses. If the local disorder is not rapidly arrested, death 
will undoubtedly ensue in spite of all general means, and no time 
should be lost in trying inefficient remedies. A powerful caustic 
is the only hope. The gangrenous spot should be destroyed by 
the actual cautery or muriatic or nitric acid, the patient being 
under the anaesthetic influence. After this, disinfectant poultices 
should be applied, and every effort at sustaining the vital forces 
continued, and should a fresh gangrenous spot appear, a new 
application of the caustic should be resorted to. 

1 Diet, de Med., vol. xxx. p. 991. 



94 DISEASES OF THE VULVA. 



Inflammation of the Vulvo- Vaginal Gland. 

Anatomy. — Just anterior to the hymen, or its remains, the carun- 
culse myrtiformes, will he found on each side a little opening, 
sufficiently large to admit a small prohe or bristle. This opening- 
leads through a canal three-fifths of an inch long, which is the 
excretory duct of a conglomerate gland which has received the 
name of vulvo-vaginal gland. These glands are found on each 
side of the ostium vaginas between the vagina and the ascending 
branch of the ischium, from which they are distant three-tenths of 
an inch, and lie in contact with the transverse artery of the peri- 
neum. The fact that they are separated from the vagina by an 
aponeurotic prolongation, lie between the superficial and middle 
layers of the ischio-pubic fascia, and have the unyielding ischium 
on one side, accounts for the complete confinement of pus forming 
in their tissue, and its not being discharged by the rectum or 
vagina. They were described by Duverney, Bartholinus, Mor- 
gagni, and their immediate successors, but in time, very singu- 
larly, they were lost sight of. In 1841 M. Huguier, of Paris, re- 
described them fully, and threw much light upon their diseased 
conditions. 

Sometimes, their mouths becoming occluded by adhesive in- 
flammation, their secretion is retained, and they undergo great 
enlargement and distension. At others their proper tissue be- 
comes inflamed, as we see that of the breast does in mammitis, 
and abscess is the result. 

Causes. — The causes of inflammation of these glands are very 
much the same as those of vulvitis, of which, indeed, this affection 
is often a concomitant disorder. 

Symptoms. — There is heat about the vulva, pruritus, and paiD 
upon touch. The mouth of the duct is red, and the finger pressed 
over the site of the gland discovers a hard, painful, and perhaps 
fluctuating tumor about the size of a large almond. 

Course and Duration. — The disease is one of no great moment, 
and its natural tendency is to recovery. Its usual course is from 
two to three weeks, and the inflammatory process may terminate 
either by resolution or by suppuration. Should the latter occur, 



ERUPTIVE DISEASES OF THE VULVA. 95 

the pus may be discharged through the ducts of the gland, near 
them, or in the furrow between the labia minora and majora. 

Treatment — An emollient poultice or cooling and anodyne 
lotion should be kept applied to the vulva, and rest should be 
prescribed until suppuration has occurred. Then, if pain is very 
severe, the accumulated pus may be evacuated by means of a 
lancet, near the mouth of the gland or at any other point where 
fluctuation is most distinct. If pain is not severe, the evacuation 
of the pus may be left to nature. 

"When frequent return of the morbid process makes it advisable 
to resort to an operation to give permanent relief, extirpation of 
the gland may be practised. An incision should be made at the 
point where one labium minus unites with the labium majus, 
through which the gland may be seized by forceps and dissected 
out with scissors. The transversus perinsei artery will probably 
be severed, and must be ligated for fear of hemorrhage. 

Eruptive Diseases of the Yulva. 

The skin and mucous membrane making up the vulva may, 
like that of other parts of the body, be affected by eruptive dis- 
orders of various kinds. It is not my intention to enter with any 
minuteness into the consideration of these diseases, for which I 
refer the reader to any of the modern works upon dermatology, 
but merely to note the fact that they may occur at this part and 
mention the leading characteristics of the most frequent of them. 
Any eruptive disorder which may elsewhere affect the skin or 
mucous membrane of the body may show itself at the vulva. 
The following list includes those which are most commonly met 
with and most frequently call for diagnosis and treatment : — 

Prurigo and lichen ; 

Eczema ; 

Acne; 

Elephantiasis ; 

Erythema and erysipelas ; 

Syphilides. 
As is the case elsewhere with prurigo, that of the vulva presents 
large scattered papules, very irritating and generally having their 



96 DISEASES OF THE VULVA. 

apices bereft of cuticle. Lichen shows papules more numerous, 
and resting upon a thickened and somewhat indurated cutaneous 
basis. 

In eczema the surface is red, heated, and covered by little vesi- 
cles, which, breaking, give forth a serous fluid. 

Acne consists in engorgement of the sebaceous follicles stud- 
ding the labial faces ; not in inflammation, which would bring the 
case under the head of follicular vulvitis, but merely in engorge- 
ment by their own retained secretion. 

Elephantiasis of the labia differs in nothing from that of other 
parts. 

Erythema and erysipelas are simply accompanied by graver 
symptoms when they affect the genital organs than when they 
develop on the skin elsewhere. 

Syphilis in secondary and tertiary form may affect the labia, 
creating hypertrophy, ulceration, and all the evils which it 
excites in other parts. 

These disorders create the ordinary symptoms of vulvitis, and 
hence they are commonly confounded with it. Pruritus vulvae is 
one of their most constant signs, and the itching which it produces 
often first attracts attention to their presence. Little need be here 
said of treatment, for it should be guided by the rules which 
govern the management of the same cutaneous disorders»in other 
parts of the body. 

Phlegmonous Inflammation of the Labia Majora. 

The areolar and adipose tissues, which in great degree make 
up the bulk of the labia majora, are very frequently the seat of 
inflammation and abscess. The disease is excited by irritating 
vaginal secretions, vulvitis, direct injury, and the peculiar blood 
state which results in the development of furuncles and car- 
buncles. 

Symptoms. — In the first stage there is active congestion, which 
in the second produces hardness and tension from effusion of 
liquor sanguinis into the areolar tissue. The third stage con- 
sists in the breaking down of this mass by the process of suppu- 
ration and formation of abscess. The pus which is thus created 



EUPTURE OF THE BULBS OF THE VESTIBULE. 



97 



is usually very offensive from pro- Fi s- 24 - 

pinquity to the rectum and vulva. 
Fig. 24 represents the disease. 

The diagnosis is usaally very 
easy. Attention is directed to the 
part by heat, pain, throbbing, diffi- 
culty of locomotion, and exquisite 
sensitiveness upon pressure. Upon 
physical exploration one labium is 
found very much swollen, and quite 
hard and tender. Although this 
is usually the case, care must . al- 
ways be taken to differentiate it 
from labial hernia, displacement 
of an ovary, pudendal hematocele, 
oedema labiorum, and vulvitis. 
As this point will engage our at- 
tention elsewhere, it requires no 
further mention here. 

Treatment. — The treatment should 
consist, in the first stage, of the application of cold and sedative 
lotions, low diet, saline cathartics, and perfect rest. One of the best 
local applications will be found to be the lead and opium wash 
As the second stage advances the process of suppuration, whicn 
is now inevitable, should be fostered by poultices, and as soon as 
pus is distinctly discoverable it should be evacuated by puncture. 
Early opening is advisable, because the tissues obstinately resist 
natural evacuation, and the accumulation may pass upwards 
towards the abdominal ring through the dartoid sac. 




Phlegmonous inflammation of the labia 
majora. (Boivin and Duges.) 



EUPTURE OF THE BULBS OF THE YESTIBULE. 

Normal Anatomy. — If an incision be made by a scalpel through 
the skin and its subjacent adipose tissue, around the vulva, and all 
the tissues making up that part be dissected off, a reticulated 
plexus of large veins will be found beneath the labia called the 
pars intermedia and bulbi vestibuli. These extensive channels 
for blood have been represented by Kobelt, as shown in Fig. 25, 
7 



DISEASES OF THE VULVA. 



Any influence which causes a rupture of these vessels must 
produce one of two effects ; if there is a corresponding rupture 

Fig. 25. 




Plexus of veins of the vestibule. (Kobelt.) 

of the skin, a free hemorrhage will occur ; if not, the blood pour- 
ing out into the areolar tissue, surrounding the wounded plexus, 
will soon form a coagulum, which will constitute a bloody tumor, 
which has received the name of thrombus, or pudendal hsema- 
tocele. 

Pudendal Hemorrhage. 

Especial attention has been called to this condition by Sir 
James Simpson, 1 who, in 1850, recorded from his own experience, 
and that of others, a number of instances in which from a very 
slight rupture of one labium fatal hemorrhage had taken place. 
He declares that criminal cases have repeatedly occurred in 
Scotland, in which women, both pregnant and non-pregnant, had 
suddenly died from pudendal hemorrhage, arising from rupture of 
the bulbs of the vestibule. Suspicion of injury, at the hands of 
the husbands or neighbors, had been entertained in most or all 
of the instances referred to. 

Causes. — The great predisposing causes are pregnancy, varicose 
condition of the veins, or a large pelvic tumor. 

1 Obstet. Works, vol. i. p. 277, Am. ed. 



PUDENDAL HEMATOCELE. 99 

The exciting causes are : — 

Great muscular efforts; 1 

Blows rupturing the labia ; 

Incisions or punctures ; 

Passage of the child's head through the pelvis ; 

Delivery by forceps. 
Symptoms. — The hemorrhage which accompanies the accident 
will lead to a physical exploration, which will at once reveal the 
nature of the lesion. 

Treatment. — The nature of the accident being once recognized, 
the control of the flow will not be difficult. If it is not effected by 
cold and astringents, such as the persulphate of iron or tannin, 
the actual cautery will probably check it without delay. Before 
resorting to this powerful means, however, a stick of nitrate of 
silver should be passed into the bleeding opening and held there 
until coagulation of the albuminous elements of the blood is 
caused. Then pressure, kept up by means of a bandage and com- 
press, will probably accomplish the end in view. 

Pudendal Hematocele. 

Definition and Synonymes. — The term thrombus, derived from 
the Greek 0poju/3ow, " I coagulate," and which is used synonymously 
with hematoma and sanguineous tumor, is that which is gene- 
rally applied to this condition. I have preferred the appellation 
of pudendal hematocele, given to the disorder by Dr. A. H. 
McClintock, from its pointing out the similarity between it and 
pelvic hematocele, which resembles it in pathology. 

Pudendal hematocele is a tumor formed by a mass of clotted 
blood effused into the tissue of the labia, the wall of the vagina, 
or the areolar tissue immediately surrounding these parts. 

History. — As early as 1554, the disease was mentioned by 
Rueff, of Zurich, and in 1647 Yeslingius is said by Dr. Merriman 
to have noticed it. It attracted the attention of Kronauer, of 
Basle, in 1734, and subsequently that of Levret, Boer, Audibert, 
and others. 2 But in time it passed somewhat out of notice, until 
the researches of Deneux, 3 in 1830, drew attention to it in more 

1 Prof. Simpson records a case due to straining at stool. 

2 Velpeau, Diet, de Med., vol. xxx. 

3 Sur les Turneurs sanguines de la Vulve et du Vagin, 



100 DISEASES OF THE VULVA. 

recent times. It is generally alluded to by authors only as 
one of the results of pregnancy and parturition, though it is 
incontestably proven that it may occur in the non-pregnant, and 
even in the virgin state. Yelpeau records an instance in a girl of 
fourteen years, who had not yet arrived at puberty, and declares, 
as the result of his experience, that " thrombus vulvae occurs 
almost as frequently in non-pregnant women as in those who are 
in labor." He declares that he has, in the course of one year, 
observed six cases in the non-pregnant woman ; and, in all, he 
has met with twenty instances. 

Pathology. — The pathology of this condition is identical with 
that of pudendal hemorrhage, which has just received notice, for 
both are results of rupture of the bulbs of the vestibule. In 
that Avhich we are now considering the effused blood, instead 
of pouring away, collects in the tissue of the labia, under the 
vagina, or even in the areolar tissue of the pelvis, and forms a 
coagulum. It bears to the first mentioned the same relation which 
a simple fracture bears to one of compound character. 

Eupture of a branch of the ischiatic or pudic arteries may, 
during labor, likewise produce a bloody tumor, 1 but this should 
not be treated of under the technical head of thrombus, for it 
would really constitute a case of false aneurism. 

Mode of Development. — When a large vessel has been injured, a 
tumor — perhaps the size of an orange — is suddenly discovered at 
the vulva. At other times the tumor is quite small, not larger 
than a hickory-nut. The extent of the laceration likewise go- 
verns the rapidity with which the tumor forms after the injury 
has been inflicted. In some instances a slight flow slowly con- 
tinues until compression from the clot checks it. Thrombus 
occurring in the non-pregnant state is generally less extensive 
than that in pregnancy, and is usually confined to the vulva. 

Causes. — The causes are identical with those of pudendal hem- 
orrhage : — 

Muscular efforts ; 

Blows rupturing the labia ; 

Incisions or punctures ; 

Passage of child's head in labor ; 

Delivery by forceps. 

1 Meigs' Treatise on Obstetrics. 5th ed.. p. 94. 



PUDENDAL HEMATOCELE. 101 

Symptoms. — The symptoms are usually a sense of discomfort, 
with pain and throbbing, and if the effusion reaches the urethra, 
there is obstruction to urination. The patient or attendant will 
often first recognize the fact that something abnormal has 
occurred by the sense of touch, practised without a suspicion of 
the real difficulty. 

Differentiation. — Care must be observed not to confound the 
accident with — 

Abscess of the labia ; 

Pudendal hernia ; 

Inflammation of vulvo-vaginal glands ; 

A mass of feces in the rectum ; 

(Edema labiorum. 
The mere announcement of the possibility of error in diagnosis 
is all that is necessary, for the physical characteristics, mode of 
development, and rational signs of these affections are so differ- 
ent from those of thrombus, that examination will always settle 
the point with certainty. 

Prognosis. — If the sanguineous collection be small, it will, 
especially in the non-pregnant state, generally disappear. If, 
however, it be large, and if the patient has recently been deliv- 
ered, there are always two dangers to be apprehended. The lesser 
of these is hemorrhage ; the greater, purulent infection through 
the walls of the cyst left empty by evacuation of the clot, or the 
formation of an extensive abscess, which may produce the same 
result. 

Natural Course. — Should the tumor be uninterfered with, it 
may in a few days be absorbed, and leave no trace; or in five or 
six days it may burst and discharge; or the clot may become 
encysted, and remain indefinitely in the vulva. 

Treatment. — Should the tumor be small, and not excite much 
pain, a cooling lotion of lead and opium should be applied, the 
patient kept quiet, and the evacuations of the bladder and rectum 
regulated, in the hope that absorption will take place. So soon 
as evidences of phlegmonous inflammation around the tumor 
appear, suppuration and discharge should be encouraged by poul- 
tices. When the tumor is large, and we feel sure, on this account, 
that it will not undergo absorption, it is advisable to e vacua to the 
blood-clot by incision. This should be done by means o^ a bis- 



102 DISEASES OF THE VULVA. 

toury upon the mucous face of the labium majus, the patient 
being placed under the influence of an anaesthetic. After an in- 
cision has been made, one finger should be inserted, and the clot 
turned out of its nidus. If hemorrhage ensue, the cyst should be 
thoroughly washed with solution of the persulphate of iron, and 
pressure exerted. Should this not check it, pledgets of lint soaked 
in this astringent should be passed into the cyst, and, if necessary, 
counter-pressure exerted per vaginam by a tampon of cotton. 

Pudendal Heenia. 

Normal Anatomy. — By some anatomists it is stated that the 
round ligaments of the uterus end in the mons veneris ; but this 
view is not generally accepted. A more careful dissection traces 
them through the internal abdominal rings, along the inguinal 
canals, to the labia majora, where they are lost in the dartoid sacs, 
described by Broca as passing through these folds. The labia 
majora are unquestionably the analogues of the scrotum of the 
male, and the round ligaments are those of the spermatic cords. 

Definition. — Down one of these canals, by the side of the round 
ligament, a loop of intestine, and sometimes a portion of the me- 
sentery, an ovary, or even the bladder, may pass, as inguinal 
hernia occurs in the male. 

The fact that this disease is by no means frequent, makes its 
recognition the more important, for were the practitioner not 
aware of the possibility of its occurrence, the intestine might be 
opened into, under the supposition that the labial enlargement 
was due to abscess, or distension of the vulvo-vaginal glands. 

Causes. — The displacement may be produced by violent mus- 
cular efforts, or blows, or falls, as in the male. 

Symptoms. — Strangulation of the intestine may occur, according 
to Sir Astley Cooper and Scarpa, 1 although it is very rare, and 
may usually be overcome by taxis. In one case with which I 
have met, reduction was extremely difficult, and could only be 
accomplished by prolonged effort. 

The nature of the case will at once be suspected, from the pecu- 
liar gaseous or airy feel yielded to the sense of touch. Certainty 

1 Scanzoni, op. cit., p. 560. 



PRURITUS VULVAE. 103 

of diagnosis will be arrived at by absence of all signs of inflam- 
mation or oedema, impulse felt upon coughing, resonance upon 
percussion, and the possibility of diminishing the volume of the 
tumor by taxis and position. There are no difficulties attending 
the differentiation of the disease. The danger is that the possi- 
bility of hernia at this point may be forgotten, and deductions 
drawn without considering it. 

Treatment. — The patient having been placed in the knee-elbow 
position, the tumor should be grasped, compressed, and pushed 
up the canal, clown which it has descended, until it returns to the 
abdomen. Then a truss, so arranged as to press upon the exter- 
nal abdominal ring, should be adjusted, and worn with a perineal 
strap, to make pressure upon the labium, and keep the compress 
of the instrument sufficiently low down. 

Pruritus Vulvae. 

Definition. — This affection consists in irritability of the nerves 
supplying the vulva, which induces the most intense itching and 
desire to scratch and rub the parts. Although not itself a disease, 
it is always so important, and often so obscure a symptom, that 
it requires special notice and investigation. 

Pathology. — It has just been stated that it consists in disorder 
of the nerves supplying the vulva. It matters not whether this 
be a true neurosis or one secondary to some other pathological 
state, the great element of pruritus vulvae is nervous irritability 
or hypergesthesia. That it is often excited by irritating discharges 
and eruptive disorders there can be no question. Whether it 
ever depends upon idiopathic nervous hyperesthesia, as some 
suppose, is doubtful. I have never met with an instance in which 
it appeared to do so. 

Mode of Development and Course. — In the beginning, the irrita- 
bility and tendency to scratch are sometimes very slight, so as 
to annoy the patient very little and give her but trifling uneasi- 
ness. Sometimes they exist only after exertion, in warm weather, 
upon exposure to artificial heat, or just before and after menstrua- 
tion. The disorder is aggravated by the counter-irritation which 
it demands for its relief. The rubbing and scratching which are 



104 DISEASES OF THE VULVA. 

practised cause an afflux of blood, render the skin tender and its 
nerves sensitive, and in time greatly augment the evil by produc- 
ing a papular eruption. The disease, and the remedy which in- 
stinct suggests, react upon each other, the first requiring the 
second, and the second aggravating the first, until a most rebel- 
lious and deplorable condition is developed. It would be difficult 
to exaggerate the misery of some of these cases. The patient is 
bereft of sleep by night, and tormented constantly by day, so that 
society becomes distasteful to her, and she gives way to despond- 
ency and depression. It is generally intermittent, in some cases 
occurring by night, in others only at certain periods of the day. 
In two cases with which I have met, the patients were free from 
all irritation except at night, when the disturbance and nervous 
anxiety became so intense as to prevent sleep, except when large 
doses of opium were given. Loss of sleep, the use of opium, and 
the nervous disturbance incident to the disease, often prostrate 
and exhaust the patient to an astonishing extent. 

Its duration has no limit, many months sometimes passing 
before relief is obtained. 

Causes. — Every practitioner dreads to take charge of an aggra- 
vated case of pruritus, for he knows how obstinate the malady 
commonly proves. The only reasonable hope of controlling it 
must rest in viewing it strictly as a symptom, and striving to 
discover and remove its cause. No fixed prescriptions, however 
much lauded in its alleviation, should be relied upon. The pri- 
mary disorder should be sought for and cured, in the hope of re- 
moving one of its results which is most pressing in its demands 
for relief. Should the case have progressed for some time, it will 
often be found impossible to decide as to its cause, for the friction 
excited by it will frequently establish a cutaneous disorder, the 
connection of which with the pruritus, whether as cause or effect, 
will be doubtful. 

In all the instances of pruritus vulvae which I have been able 
to examine early enough to determine as to the etiology, I have 
found one of the following conditions to exist as the apparent 
cause of the hyperaesthetic condition of the nerves : — 



PKURITUS VULVAE. 105 

1st. Contact of an irritating discharge — 

Leucorrhoea ; 

Hydrorrhoea ; 

Discharge of cancer; 

Dribbling of urine ; 

Diabetes. 
2d. Local inflammation — 

Vulvitis ; 

Urethritis. 
3d. Local irritation — 

Eruptions on the vulva ; 

Animal parasites. 

Of all these, leucorrhoea is the most frequent cause. This symp- 
tom of uterine disorder fortunately produces pruritus only as an 
exception to a rule. Under certain circumstances it appears to 
possess peculiarly irritating and excoriating qualities, which, even 
when the flow is very slight in amount, will excite the most in- 
tolerable itching. This feature is most commonly observed in 
the discharge attending pregnancy ; and in that of senile endome- 
tritis, which covers the vagina with bright red spots, and gives 
it a glazed look like serous membrane. In an exceedingly obsti- 
nate case, occurring in a woman of seventy years, the leucorrhoeal 
discharge was so small in amount that the patient was not aware 
of its existence, nor did I appreciate its connection with the dis- 
order until I discovered accidentally that the only relief which 
could be obtained followed the application of a wad of cotton 
against the cervix uteri. In every case of pruritus the vagina 
should be carefully investigated for evidence of leucorrhoea unless 
some other sufficient cause is apparent. In the same manner the 
other vaginal discharges mentioned may set up nervous irritability 
in the vulva. 

I have so often found diabetes accompanied by this symptom 
that I always examine the urine in obscure cases. This result is 
probably not connected with the constitutional effects of the dis- 
ease upon the nerves, but with some direct and local influence 
exerted by the disordered secretion. 

Local inflammation, by the discharge which it excites and the 
itching which attends it, is very evidently calculated to give rise 



106 DISEASES OF THE VULVA. 

to pruritus; and yet cases thus established are not the most 
rebellious with which we meet. 

Any form of eruption upon or around the vulva may, and usu- 
ally does, excite itching. Eczema, prurigo, lichen, and many 
others, may do so here as they do elsewhere, and the natural 
warmth of the part, formed as it is of folds of tissue and covered 
by hair which is thickly interspersed with sebaceous and piliferous 
glands, makes them the more likely to prove active in causing it. 

Animal parasites of two varieties may give rise to it, the pedi- 
culus pubis and the acarus scabiei. The first excites enough 
irritation to beget a lichenoid eruption, while the second produces 
scabies or itch. 

One of these causes will generally be found to have given 
rise to pruritus vulvas, but it is only in originating the difficulty 
that it will prove active. Yery soon secondary influences, as 
eruptions, excoriations, ulcerations, and increased discharges the 
results of scratching, superadd themselves as auxiliary agents, 
and keep up the difficulty. 

Treatment. — It has been stated that the first effort of the prac- 
titioner should always be to discover the disease of which the 
pruritis is a symptom, and to endeavor to remove it by appro- 
priate means. Should leucorrhoea be the cause, the uterine or 
vaginal affection which gives rise to it should be treated. Should 
an eruptive disorder be found to be the source of the difficulty, 
the measures which would be advisable elsewhere, laxatives, 
baths, change of air, tonics, and arsenic would be equally bene- 
ficial here. 

But this will not be sufficient. While eradication of the mis- 
chief is thus attempted, palliative means must be vigorously 
adopted for the sake of present relief. Should the case be re- 
garded, upon careful investigation, as due to contact of an irritat- 
ing fluid with the nerves of the vulva, perfect cleanliness should 
be secured by three, four, or, if necessary, a larger number of 
sitz baths daily. The vagina should, at the time of taking each 
bath, be syringed out with pure or medicated water, the irritated 
surface protected by unctuous substances, or inert powders, as 
bismuth, lycopodium, or starch, from the injurious contact, and 
in case the discharge comes from the uterus, a wad of cotton 
should be placed daily against the cervix uteri to prevent its 



COCCYODYNIA. 107 

escape to the vulva. A very useful vaginal injection, and wash 
for the vulva, under these circumstances, is the following : — 

R. — Plumbi acetatis, gij. 
Acidi carbolici sol. gj. - 
Tr. opii, ^iv. 

Aquae, Oiv. — M. 

This may relieve itching for the time, until removal of the 
cause of the symptom is accomplished. 

In case the pruritus is the result of a local inflammation, this 
should be treated as elsewhere recommended, by poultices of lin- 
seed, potato, or slippery elm, to which have been added a proper 
amount of lead and opium; or fomentations of lead and opium 
wash, or poppy-heads may be used in their stead. If vaginitis 
be present, great relief will often be obtained by painting the 
lining membrane of the canal over with a strong solution of 
nitrate of silver, or by touching the whole surface lightly with 
the solid stick. 

Should an eruptive disorder be the exciting cause, it should, as 
already stated, be treated upon general principles. Meantime 
temporary relief may be obtained by painting the surface of the 
vulva over with a solution of nitrate of silver (3j to 3j), the use 
of the ungt. creasoti, ungt. chloroformi, or ungt. atropise of the 
U. S. Dispensatory. Dr. Simpson advises an infusion of tobacco. 
Should eczema or lichen have produced inflammatory action in 
the skin and subcutaneous areolar tissue, poultices, &c, should be 
employed, as if local inflammation was the cause of the affection. 

While these palliative and curative means are being adopted, 
sleep should be secured by preparations of opium, or one of its 
substitutes, codeine, cannabis Indica, hyoscyamus, or chlorodyne. 
At the same time the general state of the patient should be im- 
proved by vegetable and mineral tonics, good food, and fresh air. 
In some cases more benefit will arise from the use of iron, the 
mineral acids, and sea-bathing, than from any other means. 

COCCYODYNIA. 

Definition and Frequency. — This affection consists in a peculiar 
condition of the coccyx, or the muscles attached to it, which 
renders their contraction, and the consequent movement of the 



108 DISEASES OF THE VULVA. 

bone, very painful. It is of frequent occurrence ; since attention 
has been called to it, numerous cases having been observed by 
practitioners who saw it previously without regarding it as a 
special disorder. » 

History. — Coccyodinia was described in 1861 by two observers, 
Profs. Simpson and Scanzoni. By the first it was introduced to 
the notice of English and American practitioners, under the title 
which is here employed. 

Anatomy. — The coccyx serves as a point of attachment for the 
greater and lesser sacro-sciatic ligaments, the ischio-coccygei mus- 
cles, the sphincter ani, levatores ani, and some of the fibres of 
the glutei muscles. These are thrown into activity by certain 
movements, as rising from the sitting into the standing posture, 
the act of defecation, &c, and in such acts the existence of the 
disorder which we are considering demonstrates itself. 

Pathology. — The pain which characterizes it is probably due 
to a hyper-sensitive state of the fibrous tissues surrounding the 
coccyx, or that making up the tendinous expansions of the mus- 
cles. So long as the bone is uninfluenced by contraction of the 
muscles attached to it, no pain is experienced, but as soon as 
contraction produces motion it is excited. 

Causes. — It occurs most frequently in women who have borne 

children, but is by no means confined to them. I have on two 

occasions met with it in young unmarried ladies, and Herschel- 

man# reports two cases in children from four to five years of age. 

The chief causes for it are the following : — 

Parturition; 

Delivery by forceps ; 

Falls or blows upon the coccyx ; 

Cold; 

Exercise on horseback. 1 
Symptoms. — The patient upon sitting, rising to stand, making 
any effort, or passing feces through the rectum, experiences se- 
vere pain over the coccyx. In some cases this is so severe as to 
cause the greatest dread of sudden or violent movement. In 
others, the patient is unable to sit on account of the discomfort 
caused by pressure on the bone. The most trying process is that 

1 Scanzoni. 



COCCYODYNIA. 



109 



of rising from a low seat, and, to accomplish this, the sufferer 
will obtain all the aid that is practicable, by assistance with the 
hands, which will be placed as auxiliar y supports upon the edges 
of the chair or stool upon which she rests. 

Differentiation. — The only conditions with which this may be 
confounded are painful haemorrhoids or fissure of the anus, and 
from both a careful examination by sight and touch will always 
readily distinguish it. 

Prognosis. — Coccyodynia often lasts for years, annoying and 
distressing the patient, but never to any degree depreciating her 
health or constitutional state. If left to nature, it may wear itself 
out, but it is probable that it would generally remain for a long 
time. 

Fig. 26. 




Sketch of the anatomical relations of the coccyx, a. Great saoro-soiatio ligament. f>. 
Small sacro-sciatic ligament, c. Surface from which the gluteus maximus muscle (A) has 
been detached, d. Sphincter ani. e. Levator ani. /. Coccygeus muscle. g. Fascia in 
contact with the rectum, h. Gluteus maximus of the left side. (Simpson.) 



110 DISEASES OF THE VULVA. * 

Treatment — Counter-irritation, opiates by the mouth, rectum, 
skin, and hypodermic injection have all been tried in vain in 
aggravated cases. In slight cases, blistering and the endermic 
use of morphia may effect a cure, but should it not do so promptly, 
no great length of time should be exhausted in efforts by such 
means. Eecourse should at once be had to one of the two radical 
methods of cure placed at our disposal by the ingenuity of Prof. 
Simpson. The first consists in severing the attachments of all the 
coccygeal muscles ; the second in amputating the coccyx itself. 

The first operation is performed subcutaneously by an ordinary 
tenotomy knife. This is passed under the skin at the lowest 
point of the coccyx, turned flat, and carried up between the skin 
and cellular tissue until its point reaches the sacro-coccygeal 
junction. Then it is turned so that in withdrawing it an incision 
may be made which entirely frees the coccyx from muscular 
attachments. . The knife is then introduced on the other side so 
as to repeat the section there. No hemorrhage occurs unless 
some large vessel be injured, as is always the case in subcutane- 
ous operations, and complete convalescence is rapid. 

Should this fail, as it may do, an incision should be made over 
the coccyx, the bone laid bare by severance of its attachments, 
and the whole of it removed by a pair of strong bone forceps. 
By one of these procedures cure can be confidently promised. 



CHAPTER V 



RUPTURE OF THE PERINEUM. 



Definition. — The perineum, which consists of the union of the 
tendons of a number of strong and important muscles intervening 
between the verge of the anus and that of the vagina, may by 
certain traumatic influences be torn or ruptured so as to weaken 
the normal support of the posterior wall of the vagina. 

Normal Anatomy. — From the edge of the anus to that of the 
vagina the perineum extends over a space of an inch or an inch 
and a half. It consists of skin, areolar tissue, and the tendinous ex- 
pansions of several muscles, and is covered over internally by the 
posterior wall of the vagina, which ends at the fourchette. No 
muscular tissue exists at the raphe of the perineum, but this part 
is formed by the junction of the following muscles, which have 
there a point of attachment ; the sphincter ani attached posteriorly 
to the tip of the coccyx, the sphincter vaginae passing upwards over 
the clitoris and attached to its crura, and the transversus perinei 
attached on each side to the tuberosities of the ischia. An exami- 
nation of a diagram representing this part will show that rupture 
of the perineum at the raphe will result in destruction of one of 
the fixed points, by drawing upon which the muscles there in- 
serted act, and that the other point, remaining fixed, the lips of a 
wound existing there must be made to gape. 

Another fact connected with the anatomy of this part which 
must be borne in mind, is that it is the inferior support or buttress 
for the distal extremity of the posterior wall of the vagina. This 
wall runs to the end of the perineum, arching backwards towards 
the rectum. Should its support be destroyed, the vaginal wall 
may be affected unfavorably in two ways : first, the destruction of 
the perineal raphe weakens the sphincter vaginae, and thus the 
whole of the ostium vaginae loses support; second, the distal 



112 RUPTURE OF THE PERINEUM. 

extremity of the posterior wall being carried, by the rupture and 
subsequent cicatrization, farther back towards the coccyx, the 
previously existing arch is impaired, and prolapse is rendered 
probable. Figs. 27 and 28 will explain this. 

Fig. 27. Fig. 28 





Normal perineum. Ruptured perineum. 

It is evident that the greater the extent of the laceration the 
more serious will be the evils which will accrue from it. 

Results. — The following are the evil results which may follow 
this accident, directly or remotely : — 

Prolapsus vaginae with cystocele or rectocele ; 

Prolapsus uteri ; 

Incontinence of feces and intestinal gases ; 

Prolapsus recti ; 

Cervical metritis, the result of friction. 
These evils do not follow when the accident has involved the 
perineum to so limited an extent as not to have sundered the 
union of the sphincters, or at least they are not likely to occur. 
Even when the two passages are laid into one, it is sometimes 
surprising to see how little the patient may suffer ; but generally, 
under these circumstances, her condition is truly deplorable. 
Fecal matters and gases pass without control, and the uterus, 
vagina, bladder, and rectum tend so strongly to descend, that 
exercise, muscular efforts, or tenesmus, produce weariness, pelvic 
pain, and traction upon the broad ligaments. In some instances, 
so great is the disturbance of function that the unfortunate 
woman finds herself an object of disgust to her associates and 
even of loathing to her husband. 



PROGNOSIS. 113 

Varieties. — All cases may be classed under four heads : — 

1. Superficial rupture of the fourchette and perineum, not in- 
volving the sphincters ; 

2. Eupture to the sphincter ani ; 

3. Eupture through the sphincter ani ; 

4. Eupture through the sphincter ani and involving the recto- 
vaginal septum. 

Causes. — The great causes of the accident are, 
Parturition ; 
Use of forceps ; 
Manual delivery ; 
Craniotomy. 

Minute details upon this subject and upon means which should 
be adopted for prevention, belong rather to a work upon obstet- 
rics. All that is necessary to state here is that parturition is the 
great exciting cause of it, and that it is never met with in nulli- 
parous women, except after removal of large tumors per vaginam. 

Prognosis. — In an incomplete case of slight character, in which 
neither the sphincter vaginas nor sphincter ani has been injured, 
no evil will probably result. Although the wound, occurring as 
it does immediately after labor, is extremely unlikely to heal by 
first intention, it may do so by the process of granulation without 
surgical interference other than binding the thighs together, and 
producing constipation by opium. 

The first and second varieties of the accident are very generally 
trifling in their consequences, and frequently pass unnoticed by 
both patient and attendant. The third is an evil of much graver 
moment, and not at all likely to undergo spontaneous cure ; while 
the fourth represents the most serious form of the condition. 

The greater the injury the less likely will be spontaneous re- 
covery, and the more probable the complications and results which 
have been mentioned. It may be affirmed, in a general way, that 
any laceration which does not entirely sever the sphincter ani may 
heal without surgical treatment, and that none Avhich converts 
the two passages into one will do so. Even when the rupture 
has been complete it has been asserted that spontaneous cure has 
taken place, but such reports need confirmation. Pen 1 once 

1 Velpeau, Traits de l'Art des Accouehenients, vol. ii. p. t>39. 

8 



114 RUPTURE OF THE PERINEUM. 

affirmed that he had seen a woman thus injured, and who passed 
her feces involuntarily, entirely recover. De La Motte declares 
that thirty years afterwards he met and examined Peu's patient 
in Xormandy, and found that no recovery had occurred. 

Treatment at Time of Occurrence. — If the case be an incomplete 
one in which it is not deemed advisable at once to resort to suture, 
an effort should always be made to secure union of the lips of the 
wound by the following means. The wound being thoroughly 
cleansed of blood clots, which would prevent union, the thighs 
should be brought together and kept in contact by a bandage 
placed around them at the knees. The patient should then be 
placed upon the side so as to cause the lochial discharge to 
flow through the superior vaginal commissure, and prevent its 
pouring over the raw surface. Opium should be given to produce 
constipation, the bladder be kept empty by use of the catheter, 
and, once or twice in every twenty -four hours, the patient should 
turn upon the back, in order that the vagina may be cautiously 
and gently syringed out with tepid water. 

This 'plan should be ' persevered with for ten or twelve days, 
in the hope that union may occur, though, unfortunately, in the 
great majority of instances, it will not be rewarded by success. 

Time for Operation. — Upon this point authorities differ widely, 
some urging immediate action, some advising delay until the effects 
of parturition have entirely passed away, while others compro- 
mise the matter by giving preference to the plan of waiting a few 
days only. To the first class belong Baker Brown, Demarquay. 
Scanzoni, Simon, and others of equal weight. Scanzoni thus 
clearly points out the advantages of early interference: "The 
operation should be performed just after the delivery, because it 
is more likely that the bleeding lips of the wound will then unite, 
and because, vivification of the edges not being necessary, the pro- 
cedure is simpler and less dangerous.'' The worst cases of the 
accident with which we meet generally follow instrumental or 
manual delivery, and when the discovery of its occurrence is made 
the patient will usually be in a profound anaesthetic sleep. Every 
operator should be prepared, under such circumstances, to attempt 
repair, for, if it succeeds, the patient will be saved much suffering, 
while failure will not in anywise depreciate her condition. I have 
in a number of instances resorted to immediate operation, and 



TREATMENT. 115 

the result of my experience leads me always to adopt it, unless 
the sphincter ani and recto -vaginal wall be implicated in the lace- 
ration to such an extent as to make the operation a serious and 
lengthy one, or to insure the passage of lochial discharge between 
the lips of the wound. Among those who are opposed to imme- 
diate interference are Eoux and Velpeau ; while Nelaton, Ver- 
nSuil, and Maisonneuve advise delay for a few days, when all 
hemorrhage will have ceased and the edges of the wound be 
covered by granulations. 1 

Treatment of Cases which have cicatrized. — The operation which 
is now universally adopted in these cases, and which has received 
the name of perineorraphy, consists in viviflcation of the edges 
of the lips of the wound and approximation of them by sutures. 
Although the accident for which this procedure is instituted was 
described by the ancients, no surgical means of cure were ever 
advised for it until the time of Ambrose Pare. He advised the 
suture, and was followed in its use by his pupil Guillemeau. Sub- 
sequently it was employed by Delamotte, Saucerotte, Trainel, 
Noel, and others. Dieffenbach employed it successfully, adding 
to the operation oblique lateral incisions involving the skin and 
areolar tissue, for the purpose of relieving tension upon the parts 
brought together by suture. 

About the year 1832, Eoux, of Paris, obtained the most bril- 
liant results in the operation, and probably its elevation to the 
position of a reliable surgical procedure was due more to his 
achievements than to those of any other individual. He employed 
the quilled suture, and cured by it four out of the first five cases 
operated upon. Although such success was obtained in France 
at this period, we find English writers, as late as 1852 and 1853. 2 
doubting the efficacy of sutures, and advising that assistance should 
be limited to aiding the efforts of nature. Of late years rapid 
advances have been made in the operation by Dr. Brown in Eng- 
land, Yerneuil, Laugier, Demarquay, and others in France, Lan- 
genbeck in Germany, and Sims, Emmet, and Bozeman in the 
United States. 

The varieties of the operation now before the profession are 
too great to require enumeration. Operators differ chiefly in these 

1 Wieland and Dubrisay, from Trans. Churchill. 

2 Baker Brown, Surgical Diseases of Women 



116 KUPTUEE OF THE PERINEUM. 

respects: some cut the tissue of the perineum or the sphincter ani, 
and employ the quilled suture, while others make no " liberating 
incisions," as the French surgeons style them, and employ the 
interrupted suture. As a type of the first class I shall describe 
the operation of Dr. Brown, and of the second that of Dr. Sims, 
explaining the omission of other methods by the statement that 
these will always succeed in effecting a cure when performed wrfch 
the requisite skill. 

Preparation of the Patient. — The general health being in proper 
condition, the bowels should be thoroughly evacuated a day or 
two before the operation by some mild cathartic, and the vagina 
thoroughly syringed out to remove secretions and quiet local 
irritation. The patient, dressed for bed, should be placed upon 
a table before a window admitting a strong light, in the position 
for lithotomy, and put under the influence of an anaesthetic. Four 
assistants will be serviceable, although three would answer the 
purpose. One of these should administer the anaesthetic, one 
should hold the knees, and the third should attend to the duty of 
sponging blood from the wound. 

Baker Brown's Operation. — The instruments required are a 
scalpel, a blunt-pointed, straight bistoury, a pair of long dissect- 
ing forceps, three large needles, several small ones, a tenaculum, 
pieces of gum-elastic catheter to act as quills, common hemp 
twine waxed, and sponges. All being in readiness, an assistant 
holds the sides of the fissure so as to secure tension, and the opera- 
tor, by means of a bistoury, removes all the cicatricial tissue, first 
from one edge, and then from the other. This should be done so 
as not only to vivify all the cicatricial surface, but also the super- 
ficial layer of tissue above the cicatrix. After this the external 
sphincter of the anus is divided, with the skin and areolar tissue 
lying over it. The muscle is cut on both sides, about a quarter 
of an inch in front of its attachment to the os coccygis, by two 
incisions, carried outwards and backwards, as represented in Fig. 
29. For this purpose a blunt-pointed bistoury, guided by the fin- 
ger, is carried up the rectum for an inch and a quarter, and by it 
an incision of an inch in length is made, extending outward from 
the anus, between the coccyx and tuberosity of the ischium. The 
thighs are then approximated and the sutures introduced. The 
left edge being grasped between the thumb and fore-finger of the 



TREATMENT. 



117 



left hand, a strong needle, armed with a double thread, is inserted 
an inch external to the pared surface, and passed downwards and 
inwards so as to make its point come out at the bottom of the 
denuded surface. It is then passed through the opposite lip, and 
brought out through the skin, at the same distance from the edge 
of the wound. This suture is passed at the upper angle. 



Fig. 29. 




Shows the denuded surfaces and the insertion of the quill suture before the parts are 
brought together, and also the division of the sphincter on each side of the coccyx. 
(Brown.) 

Another suture is then passed in the same manner at the mid- 
dle, which should go as deep as the septum, and even pass through 
it. A third suture is then passed at the lower angle. Two bits 
of gum-elastic catheter are now placed, one on each side, the first 
within the loops of the suture, the other at the opposite extre- 
mities. The sutures are then tightened, the opposing lips adjusted. 
and the sutures tied. 

From four to six silver sutures are then passed through the 
edges of the skin, and the operation is complete. 

Dr. Brown advises that before the patient is removed the index 



118 



KUPTUKE OF THE PERINEUM, 



finger of the right hand be passed into the rectum, and that of the 
left into the vagina, in order to ascertain that apposition is com- 
plete. The parts are then sponged, and a cold water-dressing ap- 
plied and secured by a T bandage. The patient is kept in bed 



Fig. 30. 




Shows the wound closed. (Brown.) 

upon unstimulating but nutritious diet, the bowels constipated by 
opium, and the bladder frequently emptied by the catheter. The 
deep sutures should be removed on the third or fourth clay, or on 
the fifth or sixth, and about the latter period the superficial ones 
may be withdrawn. During convalescence the vagina should be 
syringed out with warm water, or with a weak solution of chloride 
of soda, if offensive discharge exists. Constipation should be kept 
up by the use of opium for two or three weeks, and when alvine 
discharges do occur they should be encouraged, and rendered 
easy by enemata. 

Should a perineo- vaginal or rectal fistula remain, Dr. Brown 
thinks highly of the actual cautery in its cure. 

iSims's Operation. — The operation performed by Dr. Sims differs 



TREATMENT. 119 

from that just described in many respects, most notably in silver 
sutures being employed, and no section to afford relaxation being 
practised, either upon skin and areolar tissue, after Dieffenbach's 
plan, or upon the muscles of the part, after that of Horner, Cope- 
land, Cooper, and Baker Brown. 

The first operator who treated these cases by metallic sutures 
was Mettauer, of Virginia, who, in the Edinburgh Med. and Surg. 
Journal (vol. xix. p. 552), described several cases successfully 
treated by lead used as an interrupted suture. 

I avail myself of a description of Sims's operation given by Dr. 
Emmet, and published in the N. Y. Med. Journal of December, 
1865 :— 

"In the operation for closing a lacerated perineum, either par- 
tially or entirely through the sphincter ani, it is unnecessary to 
divide the muscle or to make incisions into the soft parts for the 
purpose of relieving tension. 

" As early as 1855 Dr. Sims, in the Woman's Hospital, simpli- 
fied this operation by bringing the scarified edges of the laceration 
together by means of deep, interrupted silver sutures, and from 
this time the use of the quill suture, or a division of the sphincter 
ani, has been abandoned. Further experience demonstrated a 
necessity for the use of a short rectal tube for some ten or twelve 
days after the operation, that a free escape of flatus might be un- 
obstructed. Where the laceration of the perineum has extended 
only to the sphincter, the rectal tube is not needed, and three in- 
terrupted sutures are generally sufficient ; if more extensive, so 
as to involve the muscle, two in addition are required. The first 
suture passed should be the one nearest to the rectal mucous 
membrane, and should be made to follow the laceration entirely 
around, so as to bring together the sphincter. The second should 
also include the sphincter, and be passed in the recto-vaginal sep- 
tum, just beyond the first one. The remaining sutures are intro- 
duced [as in the operation for a partial laceration of the perineum] 
through one labium about half an inch from the edge on one side, 
introduced from within outward into the other, and withdrawn at 
a point equally distant, so as to approximate perfectty apposite 
surfaces. If the laceration has extended up the recto- vaginal 
septum for some distance beyond the sphincter ani, the edges 
should be brought together down to the sphincter by interrupted 



120 RUPTURE OF THE PERINEUM. 

silver sutures, at a distance of about five sutures to the inch. On 
introducing the first suture to clear the perineum, care must be 
taken that it is passed between the first and second sutures unit- 
ing the septum, and the next one in turn between the second and 
third. Without this precaution an opening into the vagina will 
be produced just behind the sphincter, from the fact that, as one 
set of sutures is passed at a right angle to the other, on twisting 
those of the perineum tension would be exerted. This is a weak 
point, for if the tube is allowed to become obstructed, a small 
recto- vaginal opening will always result from the escape of flatus 
in this direction. I always scarify by means of scissors ; it can 
be done rapidly, and with less hemorrhage. The knees should 
be kept tied together for ten days after the operation, and the 
urine drawn with care, so that none is allowed to escape over the 
surfaces brought in apposition. 

" The sutures of the perineum are usually removed about the 
sixth day ; those within the vagina must remain for two weeks 
or longer, until the parts are strong enough to admit of the intro- 
duction of a speculum. The bowels are to be kept constipated 
for two weeks, at least in all cases where the sphincter is lacerated. 
When the bowels are acted on by either a purgative or warm 
mucilaginous injection, the success of the operation will greatly 
depend on the dexterity of the nurse in properly supporting the 
parts." 

When the lower portion of the rectal wall is involved as well 
as the perineum, it must be closed before the latter. This may be 
done by an entirely separate operation, performed a fortnight be- 
fore the other, or the two openings may be closed at one sitting. 
The rectal opening should be closed by vivification of its edges, 
and approximation by silver sutures, placed a quarter of an inch 
apart. 



CHAPTEE VI. I 

VAGINISMUS. 

Definition. — This affection consists in a peculiar sensibility or 
hyperesthesia in the nerves of the vaginal mucous membrane at 
the site of the hymen, which upon irritation produces spasmodic 
contraction in the sphincter vaginae muscle. 

Frequency. — Vaginismus is of frequent occurrence, and will 
often be met with in practice. It has received little notice hereto- 
fore, not because it is rare, but because the attention of practi- 
tioners has not been specially directed to it. Dr. Sims declares 
that during twenty-four months he met with it seventeen times, 
and during the past year I have seen four well-marked cases. 

History. — The fact that such a condition occurs and becomes a 
morbid state of considerable importance was first pointed out by 
Dr. Burns, of Grlasgow, who not only described it, but adopted an 
operative procedure which has since been revived, and is at pre- 
sent regarded as the only reliable method of cure. His views did 
not apparently attract much attention, nor was their import really 
appreciated until, at a later period, they were insisted upon by 
Profs. Simpson and Scanzoni. In 1861 it was fully described by 
Dr. Marion Sims, under the name of vaginismus, and the opera- 
tion of Burns, which will soon be described, was, with slight 
modifications, recommended by him. Through his writings and 
demonstrations of its advantages this operation has become gene- 
rally known. Since that period it has been treated of by Michon, 
Debout, Charrier, and others, in monographs, and been allotted a 
space in the various systematic works on Gynecology which have 
appeared. 

Anatomy and Pathology. — The mouth of the vagina is closed by 
a muscle of elliptical shape called the sphincter vaginae, which is 



122 VAGINISMUS. 

analogous to the accelerator urinse in the male. 1 This muscle is 
attached by its upper extremity to the corpora cavernosa and 
body of the clitoris, some of its fibres passing over that organ so 
as to compress the vena dorsalis when it is in the state of erection. 
Passing downwards so as partially to cover the plexus retiformis, 
a portion of its descending fibres decussate to the surrounding 
tissues, and some of them go down to unite with those of the 
sphincter ani, with which it forms a figure 8. 

Certain morbid states produce so great a degree of irritability 
in the nerves supplying the vulva and lower part of the vagina, 
that upon contact with foreign bodies a spasm occurs in this mus- 
cle which constitutes the disease which now engages us. Dr. 
Burns's attention was chiefly fixed upon the nervous condition, the 
pudic nerve being, according to him, the seat of the difficulty, 
while Dr. Sims has pointed out the resulting muscular spasm. It 
is curious to perceive how, from different standpoints, both were 
led to the same surgical resource. 

Causes. — This affection bears to the vagina the same relation 
which blepharospasm does to the lids, or laryngismus to the 
larynx; and, like those affections, is not ordinarily a primary 
disorder, but one which results from some special local cause. It 
may arise from excessive nervous irritability affecting the whole 
system, as is often seen in hysterical women, or be produced by 
some local disorder of apparently insignificant character. Prof. 
Willard Parker 2 reports a case which was due to an irritable 
tubercle of the meatus not larger than a flaxseed, removal of 
which resulted in cure. In other words, it may be an idiopathic 
affection, or symptomatic -only of some other disorder. 
The recognized causes of the disease are : — 

The hysterical diathesis ; 

Excoriations or fissures at the vulva ; 

Irritable tubercle of the meatus ; 

Chronic metritis or vaginitis ; 

Pustular or vesicular eruptions on the vulva ; 

Neuromata. 3 
Some of these produce it by direct irritation of the nerves of 

1 Gray's Anatomy, p. 780. 

2 Bui. N. Y. Acad. Med., vol. i. p. 439. 

* Simpson, Med. Times and Gaz., 1857, vol. i. p. 336. 



TREATMENT. 123 

the vaginal mucous membrane ; others, by creating a discharge 
which indirectly establishes the same condition. 

Symptoms and Physical Signs. — The patient will generally com- 
plain of excessive pain upon sexual intercourse, the mere attempt 
at which will throw her into a state of nervous trepidation and 
apprehension. This and sterility will probably be all which will 
have attracted her attention, though in some cases a marked ten- 
dency to spasm will have been noticed upon sudden changes of 
position, or washing the genital fissure. One or more of these 
symptoms will call for a physical exploration, when the following 
facts will be recognized. So soon as the finger is brought into 
contact with the site of the hymen, the patient will spring from 
her place, complain of agonizing pain, and become much dis- 
turbed in her nervous system. Should the examination be per- 
sisted in, introduction of the finger will be found almost impos- 
sible, and if it be forced into the canal, a violent contraction of 
the sphincter will be perceived. If, instead of the finger, a camel's 
hair brush or feather be employed, severe pain and contraction 
will follow even this application to the surface. 

There is no other affection with which this can be confounded. 
All that it will be necessary to decide concerning it, will be 
whether it is an idiopathic or symptomatic disorder. 

Course and Duration. — In its course it is unlimited. Cases are 
recorded in which it lasted for twenty-five and thirty years, and 
unless relieved by art, it will probably, in its worst forms, become 
a permanent condition. In its less severe type, and more parti- 
cularly when dependent upon some other diseased state, it may 
often be relieved by mild means, or pass away without treatment. 

Prognosis. — "From personal experience," remarks Dr. Sims, 
"I can confidently assert that I know of no disease capable of 
producing so much unhappiness to both parties to the marriage 
contract, and I am happy to state that I know of no serious trou- 
ble that can be so easily, so safely, and so certainly cured." 

Treatment. — Careful search should be made, before the adoption 
of treatment, for the cause of the affection. Should this be dis- 
covered, hope may be entertained that its removal will effect a 
cure. Should no cause be discovered, or its removal not be fol- 
lowed by recovery, the general state of the patient should be 
altered and improved by exercise, change of air and scene, vege- 



124: VAGINISMUS. 

table and mineral tonics, sea bathing and cheerful society. Ex- 
ercise on horseback has been especially advised, but rowing, 
bowling, walking, or any other which develops the system and 
improves the tone of the nervous organism, will probably answer 
as well. Local treatment calculated to soothe the excited vaginal 
nerves should then be resorted to. The free use of vaginal in- 
jections containing laudanum, creasote, or acetate of lead is some- 
times productive of good. Dr. Peaslee speaks highly of an 
ointment composed of two grains of atropine to an ounce of lard. 
This alkaloid, or the extracts of opium, belladonna, hyoscyamus, 
or stramonium, may be incorporated in an ointment, and applied 
freely over the sensitive part. At the same time the glass tube, 

Fig. 31. 




Sims's vaginal dilator. 

represented at Fig. 31, should be gently inserted into the vagina, 
and kept there for as many hours a day as practicable. Its pre- 
sence will tend to benumb the nervous sensibility and produce a 
tolerance of foreign bodies. During this treatment the patient 
should live apart from her husband. 

Should these means fail, the operations of section of the sphinc- 
ter vaginae muscle, as recommended by §ims, or of the pudic 
nerve, as recommended by Burns and Simpson, offer themselves 
as procedures promising cure. 

Sims' s Operation. — The patient being put under the influence of 
ether, and placed on the back, upon a table, the remains of the 
hymen are entirely excised by a pair of curved scissors. The 
slight hemorrhage resulting from this will soon cease under the 
application of a compress wet with ice water, or of a solution of 
the persulphate of iron. 

The index and middle fingers of the left hand are then passed 
into the vagina, so as to put the fourchette on the stretch. By 
means of a scalpel a deep incision is then made on the right of 



TREATMENT. 125 

the mesial line, terminating at the raphe of the perineum. A 
similar incision is then made on the other side, the two being 
united at the raphe, and extended to the •perineal integument and 
through its upper border. Each of these incisions will extend 
from about half an inch above the upper border of the sphincter 
to the perineal raphe, thus passing across the muscle, and measur- 
ing nearly two inches. They should pass over # the sphincter 
muscles, but not entirely through it, Dr. Sims 1 especially declar- 
ing that this is nnnecessary. 

After this, the vaginal dilator is placed in the canal, either im- 
mediately, or in about twenty-four hours, and worn for two hours 
in the morning, and three or four in the evening, according to 
the tolerance for it, which is manifested. Fig. 31 represents the 
glass vaginal dilator, which is three inches long, slightly conical, 
open at one end and closed at the other, and varying in size from 
an inch to an inch and a half in diameter. This instrument is 
kept in place by a T bandage, and should be worn for two or 
three weeks. 

Dr. Emmet has improved upon Dr. Sims's method of perform- 
ing the section, which he makes complete, so far as concerns the 
fibres of the sphincter vaginae in osculating with the sphincter ani. 
Passing the index finger into the vagina he elevates upon it the 
sphincter vaginae, which feels like a cord rolling upon it. Then 
by means of a pair of scissors, he clips the muscle upon both sides 
of the perineal junction, and the operation is complete. 

As a matter of historical interest I now give, by way of con- 
trast, the operation of Burns. The pudic nerve " is often preter- 
naturally sensible, so as to cause great pain in coitu as well as at 
other times. It may be exposed by cutting through the skin and 
fascia, at the side of the labium and perineum ; beginning on a 
line with the front of the vaginal orifice, and carrying the inci- 
sion back for two inches. The nerve being blended with cellular 
substance is not easily seen in such an operation ; but it may be 
divided by turning the blade of the knife and cutting through 
the vagina to its inner coat, but not injuring that. It may bo 
more easily divided by cutting from the vagina. Slitting merely 
the orifice of the vagina will not do ; we must carry the incision 

« Trans. N. Y. Acad, of Med., pp. 61 and 62. 



126 VAGINISMUS. 

fully half an inch up from the orifice, and also divide the mucous 
membrane freely in a lateral direction." 

Dr. Simpson has modified the operation of Burns by simply cut- 
ting the pudic nerve subcutaneously by a tenotomy knife. With 
regard to its efficiency I have no experience, but it is spoken of 
with confidence by those who have employed it. There is no rea- 
son why it should not accomplish what Sims's operation does, for 
in the latter the muscle is not cut, but the mucous membrane 
merely, so as to divide " the nerves of the part" as the author 
expresses it. The pudic nerve arises from the lower part of the 
sacral plexus, passes out of the pelvis through the great sacro- 
sciatic foramen, below the pyriformis muscle, and returns to it 
through the lesser. It then divides into the dorsal nerve of the 
clitoris and the perineal nerve. 

The act of parturition would be very likely to remove this con- 
dition entirely, but unfortunately one of the most constant of the 
results of vaginismus is sterility. This arises from the fact that 
sexual intercourse is so painful that it is imperfectly performed, 
or, as is more commonly the case, all efforts at overcoming the 
obstacle to it cease, and the woman lives absque marito. Should 
this state of things be found to exist, the patient may be thoroughly 
anaesthetized, in the hope that complete connection, accomplished 
under these circumstances, may result in pregnancy. 

For a number of interesting cases of this character the reader 
is referred to Dr. Sims's work upon uterine surgery. 



CHAPTER VII 



VAGINITIS, 



Definition and Synonymes. — The mucous membrane lining the 
vagina is subject to inflammatory action, which receives the name 
of vaginitis. It is the same disease which by certain authors has 
been described under the titles of vaginal leucorrhoea, blennor- 
rhoea, and blennorrhagia. 

Normal Anatomy. — The vagina is a canal which extends from 
the vulva to the os uteri externum. Its general form has been 
aptly likened, by Dr. Savage, 1 to that which would be assumed 
by a flexible tube if shortened to nearly half its length by a cord 
passed from end to end through one of its sides. The ridge thus 
formed is called the anterior column of the vagina, and marks the 
vesico-vaginal septum. It is about two inches long, while that 
of the posterior wall, the posterior column, as it is called, is twice 
that length. The anterior column, or cord, which shortens the 
vagina, puckers its investing mucous membrane and throws it 
into folds or rugae, which run transversely towards the posterior 
column. This mucous membrane is studded with papillae, which 
are covered by pavement epithelium. The papillae of the vagina, 
which were first fully described by Dr. 
Frantz Kilian, were regarded by him 
as sensitive in function. He represents 
them as being threadlike and filiform, 
as shown in Fig. 32. 

Much discussion has occurred amono- 

o 

anatomists as to the presence of muci- 
parous glands between the folds of the 
vaginal mucous membrane, some assert- 

n .i , t Filiform papilla 1 of the vagina. 

ing and others as positively denying iKiiian) 



Fig. 32. 




On Female Pelvic Orcrnns. 



128 VAGINITIS. 

their existence. The researches of Huschke, Jarjavay, Jamain, 
and other eminent investigators, enable us to accept their exist- 
ence as an undoubted fact, though it is curious that Charles 
Robin 1 and Sappey 2 have been unable to discover them. The 
vagina may then be said to be lined by a mucous membrane 
which is covered by epithelium, and thrown into folds which are 
studded by projecting, filiform papillae, between which lie nume- 
rous muciparous follicles. . 

Varieties. — Vaginitis assumes three forms, which differ so widely 
in their pathology, etiology, and symptoms, as to require separate 
investigation. They are denominated as follows : — 

Simple vaginitis; 

Specific vaginitis ; 

Granular vaginitis. 

Simple Vaginitis. 

Definition. — This variety of vaginitis consists in inflammation 
of the mucous membrane of the vaginal canal from some cause 
disconnected with gonorrhoeal contagiom 

Varieties. — It may exist in acute or chronic form, either of 
which types may appear originally or be the result one of the 
other. The acute form may be excited by some special cause and 
rapidly pass into the chronic ; or, originating as a low grade of 
inflammation, the disease may at any time take on the characters 
of virulence and acuity. 

Causes. — In the great majority of instances this affection, more 
particularly in its chronic form, depends upon a discharge from 
the uterus, to which it is secondary. It may, however, arise from 
any of the following exciting influences : — 

Exposure to cold and moisture ; 

Injury from pessaries or coition ; 

Disordered blood states, as in phthisis and the exanthemata ; 

Retained and putrifying secretions ; 

Chemical agents. 
After matrimony the acute form is not unfrequently excited, 
and in prostitutes, whose occupation involves an abuse of sexual 
intercourse, it is quite common. 

1 Nysten's Dictionary. 2 Descriptive Anatomy. 



SIMPLE VAGINITIS, 



129 



A bit of sponge, or other substance which retains the natural 
secretions, left in the vagina until putrefaction, occurs, will often 
induce the affection, and three of the most virulent cases with which 
I have ever met were caused by contact of a solution of chromic 
acid with the vaginal walls in making an application to the uterus. 
Symptoms. — Acute vaginitis develops itself by the following 
symptoms : — 

A sense of heat and burning in the vagina ; 

Aching and weight at the perineum ; 

Frequent desire for micturition; 

Profuse purulent leucorrhoea of offensive character: 

Violent pelvic pain and throbbing ; 

Excoriation of the parts around the vulva. 
In the chronic form the disease shows the same symptoms, 
though with much less severity. In very mild cases, only a 
slight itching or burning sensation is experienced, with discharge 
of leucorrhceal matter. 

Physical Signs. — When the inflammation is acute the labia are 
found swollen and tense, the mucous membrane of the vaginal 
canal red and covered with pus, 
and the animal heat very much 
increased. Introduction of the 
finger produces great pain, and 
often cannot be tolerated. For a 
period varying from fifteen to 
thirty hours after the inception of 
the disease, the natural secretion 
of the part is checked ; then there 
pours forth freely pus of acrid and 
offensive character, which, in a 
week or ten days, is replaced by 
muco-purulent material. This dis- 
charge is found to consist of liquor 
puris, large numbers of epithelial 
cells, pus and blood-globules, and 
an infusorial animalcule called the 
trichomonas vaginalis by M. Donne, who first described it. By 
some the last has been regarded as ciliated epithelium separated 
from the uterus, but it is probably an animalcule which exists in 
9 



Fig. 33. 




Epithelium in all stages of develop- 
ment, in simple vaginitis. 220 diame- 
ters. (T. Smith.) 



130 VAGINITIS. 

vaginal mucus of unhealthy character. M. Donne at first regarded 
it as characteristic of specific vaginitis, but subsequently renounced 
the view. 

Prognosis. — In its acute form it usually runs its course in about 
two weeks. In the chronic form it lasts for an indefinite time, 
often subsiding into ordinary vaginal leucorrhoea, or rather into 
a state of which this is the only prominent symptom. 

Differentiation. — Simple vaginitis may be confounded with — 

Gonorrhoea; 

Endometritis ; 

Pelvic abscess ; 

Cervical ulceration. 
From the first the differentiation is always difficult and fre- 
quently impossible. The means by which it may sometimes be 
accomplished will be mentioned in the article relating to Specific 
Vaginitis. From the three remaining affections it is readily dis- 
tinguishable by the speculum and vaginal touch. An error will 
be committed only when the practitioner is not alive to the possi- 
bility of its occurrence, and draws his conclusions from insufficient 
data. I have seen two cases of profuse and obstinate vaginal dis- 
charge regarded as the result of vaginitis, which were in reality 
produced by pelvic abscesses that emptied their contents into 
the upper part of the canal. An element in such cases calculated 
to mislead a superficial examiner is the fact that vaginitis does 
really exist to a limited extent as a result of the purulent flow 
from the abscess. This remark likewise holds true in reference 
to endometritis and ulceration. 

Comjjlications. — Vaginitis sometimes produces violent urethri- 
tis, and less frequently results in endometritis, Fallopian salpin- 
gitis, and pelvic peritonitis. 

Specific Vaginitis or Gonorrhoea. 

Definition and Synonymes. — This variety of the affection consists 
in inflammation of the vulva, vagina, and urethra, arising from a 
specific contagion which is transmitted by a yellow, purulent dis- 
charge. 

Pathology. — The purulent material which is the contagious 
element, after remaining for some time in contact with the vagi- 
nal walls, excites in their investing mucous membrane an active 



SPECIFIC VAGINITIS OR GONORRHCEA. 131 

hyperemia which results in heat, swelling, pain, and an ichorous 
and abundant purulent secretion. This inflammation may be 
simulated by simple acute vaginitis, but its most characteristic 
features are usually excited by the contagious influence just 
alluded to. The disease may affect all the localities above men- 
tioned at the same time, but very often it is limited to the upper 
part of the vagina, to the vulva, or to the urethra. In some cases 
it is for a length of time concealed in the vaginal cul-de-sac, no 
other part of the vagina being affected. This fact explains, says 
Alphonse Guerin, 1 how women apparently healthy transmit 
gonorrhoea. 

Causes. — As there is but one cause for scarlet fever, for measles, 
and for variola, namely, absorption of a specific poison or con- 
tagious material, so is there but one cause for gonorrhoea. It is 
true that simple acute vaginitis may simulate gonorrhoea so 
closely that the most experienced observer will be foiled in diag- 
nosis, but this fact does not prove the diseases identical. The 
poison of gonorrhoea produces inflammatory results as a certain 
consequence ; the causes of acute vaginitis produce them as an 
accident which probably in a different state of the patient's sys- 
tem would not have occurred. 2 

Symptoms. — The symptoms of this variety of vaginitis differ 
very little, indeed in many cases not at all, from those of the 
simple acute form. They may be thus enumerated : — 

Heat and burning in the vagina ; 

Aching and sense of weight at the perineum ; 

Frequent desire for micturition ; 

Scalding in the passage of urine ; 

Profuse purulent leucorrhoea of offensive character ; 

Violent pelvic pain and throbbing ; 

Excoriation of the parts around the vulva. 
Physical Signs. — The vulva, vagina, and urethra will be found 
swollen, tense, red, and hot. In the beginning they are unnatu- 
rally dry, but very soon a profuse secretion bathes them with a 

» 

1 Maladies des Organes Genitaux, p. 285. 

2 This view is denied by many of the best authorities, who regard gonorrhoea as 
having nothing specific about its nature. At the same time that I have no wish 
to ignore the opinion with which mine conflicts, I have preferred to give my own 
impressions without discussing the matter. 



132 VAGINITIS. 

creamy pus, sometimes streaked with blood. Should the affection 
have exerted its influence chiefly upon the vulva, pruritus, excoria- 
tion, and an increase of sexual appetite will be observed. Should 
the urethra be chiefly or solely diseased, instances of which are 
recorded by Eicord and Cullerier, the most violent scalding upon 
the passage of urine will especially annoy the patient. 

Differentiation. — It will be seen, from what has been already 
stated, that the differentiation of this disease from simple acute 
vaginitis must be extremely difficult. In many cases it is impos- 
sible, for there are no signs which can be regarded as positively 
conclusive. The trichomonas vaginalis, once supposed by Donne 
to be pathognomonic of specific vaginitis, is now known to exist 
in the pus of that which is simple; and urethritis, formerly viewed 
as diagnostic by many, is sometimes a complication of the simple 
form and is sometimes absent in the specific. 

The following are the symptoms which should lead us strongly 
to suspect the specific nature of a case : — 

Great virulence and acuity in development ; 

Development in a woman previously free from vaginal dis- 
charges ; 

Marked urethral complication ; 

Copious purulent discharge ; 

Transmisssion to the male from coition. 

Although it is true that in many cases these symptoms will 
render us certain in our conclusions, in many others they will 
exist in cases certainly of non-specific character. I have on two 
occasions seen them all attend cases of vaginitis, excited by acci- 
dental contact of chromic acid with the vaginal walls. 

Course, Duration, and Termination. — The duration of the disease 
will depend in great degree upon the character of the treatment 
adopted. Under proper management even a severe case may be 
cured in from two to three weeks, but if neglected it may continue 
for months and perhaps years. The morbid action passing up 
into the uterus may exist as an endometritis long after the vagi- 
nal trouble has disappeared ; or it may pass into the bladder and 
excite cystitis ; or down their narrow ducts into the vulvo vagi- 
nal glands. 

Complications. — The complications of gonorrhoea in the female 
are numerous and important. The disorder sometimes becomes 



GEAXULAR VAGINITIS. 133 

an exceedingly grave one, and, in some instances, destroys life. It 
may induce the following results : — 

Bubo or vulvar abscess ; 

Cystitis ; 

Inflammation of vulvo-vaginal glands ; 

Endometritis ; 

Fallopian salpingitis ; 

Pelvic peritonitis. 
Mr. Salmon, 1 who first drew attention to inflammation of the 
vulvo-vaginal glands as a result of the disease which we are con- 
sidering, declares that it is quite common. 

The passage of the disordered action into the uterus, through 
the tubes, and into the peritoneum, is the most dangerous of all 
its consequences and produces great risk to life, from the pelvic 
peritonitis which it excites. 

Granular Vaginitis. 

Definition and Synonymes. — This variety of vaginitis was first 
described by Eicord, under the name of Psorolytrie. In 1844, 
M. Deville, 2 a pupil of Eicord, described it fully, and it was sub- 
sequently treated of by Blatin, Gruerin, and others, under the 
names of papular, glandular, and granular vaginitis. 

Pathology. — By these writers it was regarded as an hypertro- 
phy of the muciparous follicles, lying imbedded between the 
rugae of the vagina. This hypertrophy it was thought was gene- 
rally the result of pregnancy, though it was admitted that it 
might arise from simple or specific vaginitis. Many recent 
writers deny the existence of this variety of vaginitis, and view 
it only as an hypertrophy of vaginal papillae, the result of the 
forms of the affection already mentioned. Thus Dr. Bumstead, 3 
in speaking of granulations found in the vagina as a result of 
vaginitis, says, "They have been erroneously regarded by Dr. 
Deville as peculiar to the vaginitis of pregnant women." Scan- 
zoni 4 and West 5 both* deny its existence, and upon the same 
ground, viz., the fact that Mandl and Kolliker have discovered 

1 Bumstead on Venereal, p. 172. 2 Archiv. de Med., 4th series, t. v. 

3 Op. cit. 4 Diseases of Females, Am. ed., p. 529, 

6 Diseases of Woman, Eng. ed., p. 640. 



134 VAGINITIS. 

very few mucous follicles in the vaginal mucous membrane. 
When, however, in opposition to the negative fact that these 
excellent observers, supported by Eobin and Sappey, have not dis- 
covered these glands, is arrayed the positive fact that Huschke, 
Jamain, Eichet, Becquerel, Guerin, and others have done so, the 
grounds for denial must be admitted to be insufficient. Even 
if such evidence of the propriety of admitting this variety of 
vaginitis did not exist, clinical research would corroborate the 
truthfulness of the deductions of M. Deville. The disease is 
characterized by hemispherical granulations, about as large as 
half a millet-seed, scattered thickly over the mucous membrane 
of the vagina and over the cervix uteri. 

Causes. — The glandular hypertrophy which gives to the disease 
its characteristic features and name, generally results directly from 
pregnancy, though it may be produced by either simple or specific 
vaginitis. Some women in successive pregnancies suffer from it. 

Symptoms. — It demonstrates its presence by the symptoms al- 
ready recorded as characteristic of simple and specific vaginitis. 
With these, pruritus vulvae and a lichenous eruption about the 
pubis are apt to appear. As parturition comes on and puts an 
end to pregnancy it disappears, very often without any treatment 
whatever. 

Treatment of Vaginitis. — The treatment of the various forms of 
this disease is so similar that it may be described under one head, 
modifications being suggested for those cases which have assumed 
a subacute or chronic aspect. If the case be one of acute char- 
acter, the patient should be kept perfectly quiet in bed, and loco- 
motion and sexual intercourse strictly interdicted. Pain should be 
relieved by opiate or other narcotic suppositories placed in the 
rectum, and febrile action prevented or combated by mild, un- 
stimulating diet and refrigerants. Every fifth or sixth hour the 
patient, rising from bed and seating herself in, or over, a tub of 
warm water containing sufficient boiled starch, infusion of lin- 
seed, or infusion of poppies to render it soothing, should, by 
means of a syringe with continuous jet, or an irrigator, throw a 
steady stream against the cervix uteri for fifteen or twenty min- 
utes, or even for a longer time. The methods most appropriate 
for syringing the vagina are fully described in chapter fifteen, 
and to it the reader is referred for details. 



TREATMENT. 135 

After the severity of the attack has been subdued by these 
means, the acetate of lead or sulphate of zinc, with tr. of opium, 
may be added to the water in small amount, not more than a 
drachm of the mineral preparations being dissolved in a gallon 
of fluid. As soon as the signs of acute inflammation have dis- 
appeared, the sulphate of alum, persulphate of iron, tannin, or 
infusion of oak bark. may be employed to render the fluid injected 
more decidedly astringent. At the same time laxatives should be 
administered, and ardor urinse relieved by the use of soda, potash, 
or other alkaline diuretics. Should inflammatory action run very 
high and much pain be experienced, benefit may be obtained by 
the application of leeches to the perineum, but this will rarely 
be found necessary. 

"When the acute form shows a tendency to become subacute or 
chronic, the speculum of Sims should be cautiously introduced, 
the whole vaginal canal painted over with a solution of nitrate of 
silver, one drachm of the salt to one ounce of water, and a roll 
of cotton, saturated with glycerine, placed against the cervix. 
The cotton saturated with this or some anodyne substance may 
be renewed daily with advantage, but the painting with the 
caustic solution should not be frequently repeated. After 
free vaginal injection, suppositories composed of butter of cacao 
or gelatine and gam tragacanth, with persulphate of iron, alum, 
copper, zinc, or opium, may, by means of the suppository tube 
represented by Fig. 34, be placed at intervals in the upper part of 

Fig. 34. 




Hard rubber tube with piston, for placing medicated cotton 
or suppositories in the vagina 

the vagina. The general state of the patient should be carefully 
watched, and if tonic or chalybeate treatment be indicated, it 
should at once be resorted to. 



CHAPTEK VIII. 



ATRESIA VAGINA. 



Definition and Synonymes. — The term atresia, derived from a 
privative and rpaw, " I perforate," signifies an imperforate condi- 
tion, and should in its strict import be limited to complete closure 
of an aperture or canal, but custom sanctions its application to 
any obliteration or occlusion which is so extensive as to remove 
the case from the class of strictures. 

The genital canal of the female may be imperforate at the vulva, 
in the vagina, or in the canal of the uterus itself. In the present 
essay it is proposed to treat only of those forms which affect the 
vagina and receive the appellation which serves as the caption of 
this chapter. 

History. — Hippocrates 1 refers to this condition as a result of 
labor ; Aristotle speaks of the accidental and congenital varie- 
ties ; Celsus devotes a chapter to it, and it claims attention, as we 
come down to subsequent times from Aetius, Avicenna, Lan- 
franc, Wierus, Euysch, Mauriceau, and Eoonhuysen. Heister 
and Boyer advanced our knowledge upon it, and still more lately 
Amussat, in 1835, operated for its cure with greater boldness than 
his predecessors had ventured to do. 

Pathology. — As a result of injury from mechanical or chemical 
agencies, a vagina once fully developed may close from adhesion 
of its walls, its calibre may be diminished by absolute removal 
of its component structures in consequence of ulceration or slough- 
ing, or the other parts of the female genital system- may go on to 
full development while this is arrested in its growth and remains 
a fibrous cord rather than a distensible canal. 

Varieties. — It may be either congenital or accidental ; and it may 

1 Puescb. De l'Atresie des Voies Genitales de la Femrne. Paris, 1S64. 



ATKESIA VAGINA. 137 

likewise be partial or complete. In a case of stillicidium men- 
sium, 1 presenting itself during the last winter at the clinique of 
the College of Physicians and Surgeons, I found the vagina appa- 
rently completely closed at its middle, yet permitting a slight flow 
of menstrual blood. Upon careful examination a small opening, 
admitting only a probe, was discovered, leading into a sac between 
the vaginal constriction and the neck of the uterus, which con- 
tained several ounces of thick tenacious blood. 

If the atresia be congenital, the whole canal will probably be 
found obliterated ; but this is rare. Generally the inferior, mid- 
dle, or upper part is the seat of stricture. 

Causes. — The following causes may be enumerated as produc- 
tive of it : — 

Arrest of development ; 

Prolonged and difficult labor ; 

Chemical agents locally applied ; 

Mechanical agencies ; 

Sloughing, the result of impaired vitality ; 

Syphilitic or other extensive ulcerations. 
One case which has come under my observation resulted from 
syphilis, another from prolonged labor, and another from the acci- 
dental passage of a sharp bit of wood up the vagina. Among the 
causes of sloughing from impaired vital force should be espe- 
cially mentioned the continued and eruptive fevers, typhus fever, 
scarlatina, variola, &c ; and cholera as a cause of the accident is re- 
ferred to by M. Courty. 2 Dr. Trask, of Astoria, 1ST. Y., has written 
an excellent article upon this subject, his conclusions being based 
upon thirty-six cases, of which fifteen were due to prolonged 
labor. 

Symptoms. — The disorder will demonstrate its existence only by 
incapacitating the vaginal canal for its important functions, copu- 
lation and transmission of menstrual blood. Should it occur in 
one too young or too old to require such functions from the vagina, 
no suspicion will be aroused as to its existence. The notice o£ the 
practitioner will generally be called to the patient by amenor- 
rhea or an inability to perform the act of coition. Should the 

1 This term is employed by Aetius, Tetrab. iv. p. 990. 

2 Mai. de l'Uterus, p. 3G9. 



138 ATEESIA VAGINA. 

menstrual hemorrhage have taken place, a large amount of blood 
will generally be found confined above the constricted part of the 
canal, and violent uterine contractions will have demonstrated the 
efforts which the uterus has made to expel the accumulation. 
Besides these, no other rational signs will show themselves, but 
they will be sufficient to urge upon the attendant the necessity of 
a physical exploration. 

Physical Signs. — The patient being placed upon the back, and 
the vaginal touch attempted, entrance of the finger into and up 
the canal will be found to be impossible. A little investigation 
will prove that this is not due to vaginismus, imperforate hymen, 
or adhesion of the labia majora, and the rectal touch will usually 
show the vagina running up the pelvic cavity as a fibrous cord. 

Results. — From the mere obliteration of the vagina there is no 
immediate or direct derangement. But in certain cases where 
menstrual blood is poured out by the vessels of the uterine 
mucous membrane, and is accumulated at each monthly epoch in 
the portion of the canal above the stricture, or in the uterus, which 
has been dilated to receive it, rupture of this organ or of the Fal- 
lopian tubes may occur, reflux through these tubes into the peri- 
toneum may take place and pelvic hematocele be the conse- 
quence ; or the retention of the menstrual flow may produce all 
those nervous and cerebral symptoms so characteristic of such an 
occurrence. 

Prognosis. — The prognosis of these cases as regards the possi- 
bility of removal of the abnormal state, will depend upon the 
extent and completeness of the obliteration, and destruction of 
tissue. The smaller the amount of vaginal tissue found by rec- 
tal touch and examination by a sound in the bladder, to exist, 
and the more complete and extensive the adhesion of the vaginal 
walls, the more closely will the case resemble one of entire ab- 
sence of the vagina. 

Differentiation. — Before any surgical interference is established 
for the relief of atresia, it should be differentiated from absence 
of the vagina. The latter very rarely, if ever, Scanzoni 1 says 
never, exists without simultaneous absence of the uterus and 
rudimentary development of some of the external organs of 

1 Diseases of Females, Amer. ed., p. 478. 



TEEATMENT. 139 

generation. If an obliterated vagina be present, it may generally 
be recognized as a hard, fibrous cord, by one finger in the 
rectum and a sound in the bladder. Sometimes a short cul-de-sac 
will be found at the vulvar extremity, and another at the uterine, 
which are united by a cord of fibrous character. 

Should deformity of the external genitals exist, the uterus not 
be discoverable, and no signs of distress at menstrual epochs show 
themselves, it may be concluded that the case is one of absence 
of the vagina, and not of complete atresia. But, thanks to the 
boldness of Amussat, even absence of the vagina does not pre- 
clude the possibility of establishing an artificial route. The 
importance of the differentiation consists in the fact that the 
surgeon should in such a case be doubly cautious and circum- 
spect in his efforts, and guarded in his prognosis. 

Treatment. — The sudden evacuation of menstrual blood, which 
has been for a long time imprisoned in the uterus and vagina, is 
always a procedure attended by danger. Even where the ob- 
struction has been only an obturator hymen, such an operation 
has been followed by endometritis, peritonitis, and death. The 
danger is probably dependent upon the fact that the imprisoned 
fluid distends the uterus and Fallopian tubes, and renders them so 
sensitive that the admission of air produces a septic endometritis, 
which in its course and termination resembles closely the most 
common form of puerperal fever. Such accumulations should 
not be evacuated, therefore, without great caution, and it is always 
well for the operator to announce to the patient, or her friends, 
the fact that dangerous consequences may result. 

Menstrual blood thus retained may be removed through the 
vagina, bladder, or rectum, by three operations : — 

1st. Puncture by a large trocar and canula; 

2d. Puncture by a small trocar and use of tents; 

3d. Incision by knife or scissors. 

Should the occluding space be limited in extent, a full supply 
of tissue exist on both rectal and vesical aspects, and a volume 
of menstrual blood be imprisoned above, a trocar and canula may 
be plunged through the obturator tissue or the wall of the rec- 
tum arid the fluid evacuated. In case it be thought best to effect 
the discharge more gradually, and if doubt be entertained as to 
the safety of passing a large instrument, which may require for 



140 ATRESIA VAGINA. 

its passage more tissue than the case presents, a small trocar or 
exploring needle may be employed, and the canal created by it 
dilated by systematic use of tents of sponge or sea tangle. In a 
case which I recently saw with Profs. I. B. Taylor, Hamilton, 
and Peaslee, this plan succeeded most perfectly in the hands of 
the first-named gentleman. Should incision be deemed necessary, 
the patient, thoroughly anaesthetized, and having had the bladder 
and rectum emptied, should be placed upon the back upon a 
table, in the position adopted in operating for stone. By means of a 
scalpel or pair of curved scissors, conducted up to the point of 
obliteration upon one or two fingers, the tissue should then be 
very cautiously cut, and the finger introduced into the opening 
made in the mucous membrane. By this a little force should be 
employed in order to separate, if possible, the adhering surfaces, 
or tear up a new tract. Then, one finger being kept in the rec- 
tum, and a sound in the bladder, cautious and gradual dissection 
of the canal should be practised, great care being observed to 
avoid opening into the rectum posteriorly, the bladder anteriorly 
and the peritoneum above. Dr. Emmet, whose experience in this 
class of cases has been extensive, declares that if the new tract 
be created by incisions by scissors and tearing of tissue by the 
fingers, subsequent contraction and atresia are much less likely to 
occur. According to his experience incisions made by the knife 
granulate and undergo cicatricial contraction with much greater 
rapidity. In 1832 Amussat advocated forcible pressure continued 
until the parts were softened and gave way, and when fluctua- 
tion was discovered, the use of a trocar or knife for evacuation of 
the fluid. Dr. Grraily Hewitt asserts that he rejected the use of 
the knife, and effected laceration of the tissues by tearing by the 
finger. Dupuytren followed a mixed method, performing the 
operation partly by cutting and partly by tearing the textures. 

However the operation be performed, there is always great dan- 
ger of relapse, and unless special means be adopted for maintain- 
ing the perviousness of the canal, it will invariably occur. To 
accomplish this a plug of glass, such as represented by Fig. 31, 
should be introduced into the vagina, secured by a T bandage, and 
worn for weeks. After this it should be kept in place at night for 
many months. Where the entire canal has been obliterated even 



TREATMENT. 141 

these efforts may fail and closure occur above, which gradually 
advances to the ostium vaginae. 

If no menstrual blood has been imprisoned above the stric- 
tured portion of the vagina, the canal should be kept scrupulously 
clean by injections of tepid water practised twice a day. If the 
uterus and tubes have been distended by retained fluid, the cavity 
of the former should, just after the operation, be carefully washed 
out with tepid water very slightly impregnated with carbolic acid 
or Labarraque's solution of soda. The patient should then be 
kept as quiet as possible in the recumbent posture, and under the 
full influence of opium. 

The period at which operation should be resorted to is a sub- 
ject of importance. Yelpeau advocates operating in infancy, but 
Puesch, Boyer, and others regard the age of puberty and approach 
of menstruation as a more appropriate time. Should the meno- 
pause have arrived, no operation will be called for. 

It should not be forgotten that delay in interference is often 
very disastrous during the period of menstrual activity, for lives 
have, in numerous instances, been destroyed by rupture of the 
Fallopian tubes, and even of the uterus itself, as seen by Puesch. 
This observer drew his conclusions from 258 cases of atresia, in 
18 of which rupture of the Fallopian tubes from distension by 
menstrual blood occurred. In one instance of atresia I saw an 
hematocele the size of an infant's head, result from regurgitation 
of blood through the tubes into the peritoneal cavity. 



CHAPTER IX. 

PROLAPSUS VAGINA AND VAGINAL HERNIA. 

PROLAPSUS VAGINA. 

Definition and Synonymes. — The mechanism by which the pelvic 
organs of the female are kept in their proper positions and rela- 
tions to each, other offers, in its simplicity and perfectness, an 
excellent example of the adaptation of means to an end which is 
so often repeated in the animal economy. The uterus is so sus- 
tained that when necessity requires it, not only in pregnancy but 
under a number of other circumstances, it may rise or fall, or tilt 
backwards or forwards, and the rectum, bladder, and lowest layer 
of small intestines are kept in place and allowed to distend and 
empty themselves without material change of relation. 

The three organs which are mainly instrumental in this result 
are the vagina, the peritoneum, and the pelvic areolar tissue. 
The first of these performs an important part. By it the uterus 
and super-imposed layer of small intestines are to a great extent 
supported, the bladder is prevented from falling backwards when 
in a state of repletion, and the anterior wall of the rectum from 
undergoing displacement forwards. 

When the tone of the walls of the vagina is impaired and they 
pouch into its own canal so as to fall downwards towards the 
vulva, the condition is called prolapsus. As, however, loss of 
the support which the vagina previously gave usually results in 
descent of the uterus, small intestines, bladder, or anterior wall of 
the rectum, it is often included under the names of prolapsus 
uteri, cystocele, enterocele, or rectocele. As considerable diver- 
sity of opinion exists as to the nature of prolapsus vaginae, it is 
necessary for us, before proceeding, to comprehend its definition 
with perfect clearness. By some it is maintained that hernia of 



PROLAPSUS VAGINA. 143 

neighboring viscera into the vagina should not be included under 
the head of prolapsus, which, as Colombat declares, is an " inver- 
sion of the internal lining membrane, caused by infiltration of the 
cellular texture that unites the mucous to the subjacent mem- 
branes." By others it is believed that true prolapse is impossi- 
ble without simultaneous displacement of one or more of the 
surrounding pelvic organs. All admit, of course, that in such an 
exuberant development or hypertrophy as that which occurs 
during pregnancy, a portion of the canal may be forced out of 
the vulva, but this is not what is ordinarily meant by the term 
prolapsus vaginae. Dr. Savage 1 expresses himself thus upon the 
point: " Prolapse of the vagina alone, or prolapse of the vaginal 
mucous membrane alone, are two affections which, anatomically 
considered, would seem impossible." The text-books, however, 
mention both. Noel mentions a case of this kind where the 
prolapse reached down to the knees ! It is an important ques- 
tion whether there can be prolapse of the vagina without vagino- 
rectocele, vagino-cystocele, vaginal hernia of intestine forcing 
down the vaginal cul-de-sac, or uterine prolapse. When the 
vagina has lost its elasticity by excessive and frequent distension, 
the vaginal canal is often occupied by a collocation of its own 
folds, which may form a considerable projection at the vulva ; 
but this does not constitute true prolapse of the vagina. 

Upon the whole, it would be unsafe to look upon any vaginal 
prolapse as unconnected with one or other of the above-mentioned 
affections, and it would be most unjustifiable to treat it as a pro- 
lapse of mere mucous membrane. 

The anterior or upper wall of the vagina is closely bound to the 
base of the bladder and front of the cervix uteri, and by means of 
the utero-sacral ligaments it is indirectly attached to the sacrum. 
This wall aids powerfully in support of the uterus, bladder, and 
small intestines. The posterior wall is not so firmly bound to the 
rectum, though the adhesion from the extremity of the utero-rectal 
pouch of peritoneum is quite strong. At the vulva the vagina is 
fixed by the deep perineal fascia and closed by the sphincter 
vaginse muscle. These anatomical arrangements account for the 
fact that prolapse of the vagina without simultaneous displace- 

1 Female Pelvic Organs. 



144 PROLAPSUS VAGINJB. 

ment of one or more of its surrounding viscera is exceedingly 
rare, and that when it does occur as a distinct disease it is very 
generally found to affect only the posterior wall. 

Pathology. — Any influence which impairs the natural tonicity 
and strength of the vaginal canal, renders it abnormally volumi- 
nous and lax. or destroys its lower buttress or support, will tend 
to induce the affection? As pregnancy and parturition combine 
most, and sometimes all, of these, they are generally found to be 
predisposing, and very frequently exciting circumstances. The 
development of the vagina, and increased weight of the uterus de- 
pendent upon the former, and the distension of the canal and 
stretching of the sphincter incident to the latter, all unite in 
bringing about prolapsus. The affection is very rare, except in 
those who have borne children, although it may occur. Sir Astley 
Cooper met with it in a girl, aged seventeen, who was admitted 
into G-uy's Hospital, for supposed prolapsus uteri, and Prof. Meigs 1 
mentions that Dr. Mutter, of Philadelphia, saw it occur in a child 
six months old in consequence of a convulsion. 

Causes. — From what has just been said the following causes will 
naturally suggest themselves as those most likely to produce this 
displacement : — 

Violent efforts of the abdominal muscles : 

Repeated parturition ; 

Excessive weight at uterine extremity of the vagina; 

Senile atrophy of vaginal walls : 

Rupture of perineum : 

Distension by pessaries, or tumors : 

Long-continued vaginitis. 
It is evident that these causes act either by debilitating the 
power of the vaginal walls by mere mechanical distension, by 
specifically robbing them of their tonicity, or by removing the 
buttress against which the canal rests at the vulva. 

Varieties. — The displacement may be of two forms, sudden and 
gradual. The power of the canal may be overcome by a violent 
effort, a fit of coughing, uterine or abdominal contractions, or simi- 
lar acts, which, with great suddenness, force the contents of the 
abdomen down upon the pelvic viscera. This occurrence, which 

1 Translation of Colombat. 



SYMPTOMS. 145 

is very rare, is generally accompanied by sudden descent of the 
uterus, or follows parturition. The ordinary form of the affection 
is that in which by the slow and steady action of one or more of 
the causes enumerated, the resistance of the vagina is gradually 
overcome, and little by little a fold is forced downwards towards 
and through the vulva. The first variety is the result of a few 
minutes' effort ; the second, that of months, or even years of mor- 
bid action. Prolapse of one wall, partial prolapsus, as it has 
been styled, is often lost sight of in view of the hernia of the 
bladder, rectum, or small intestines, which accompanies it. Hence 
cystocele, rectocele, and enterocele may be regarded also as varie- 
ties, although, strictly speaking, they are complications of the 
affection. 

Course, Duration, and Termination. — A sudden attack of prolap- 
sus being overcome by proper means, and the patient kept quiet, 
may disappear, and not return ; but in that variety which occurs 
gradually there is no limit to the disease. Generally, the physi- 
cian is not called until it has existed for a long time and become 
complete. Fortunately, it has no serious results, except the occur- 
rence of the hernias just alluded to, and these prove only annoy- 
ing, not dangerous to life. 

Prognosis. — The prognosis as to cure will depend upon the 
degree and duration of the malady. It is always, whatever be its 
extent, relievable by surgical means, but often proves incurable 
to those of medical character. 

Symptoms. — Should displacement of the vagina exist alone, that 
is, without creating hernia of surrounding organs, the patient will 
complain of a sense of discomfort in the vagina, with a tendency 
to bearing down, as if to expel some foreign body ; a feeling of 
heat, fulness, and throbbing at the vulva ; a certain amount of 
pelvic uneasiness in walking, or making any muscular effort, and 
a general tendency to prostration of the physical forces, if the 
condition be one of aggravated character. Physical exploration 
will reveal the presence of a tumor beween the labia, which touch 
will demonstrate to contain no liquid, and yet not to be solid in 
its nature. Sometimes the mucous membrane covering it is 
excoriated, ulcerated, and purple in color ; at others it will be 
smooth,shining, tough, and covered by pavement epithelium. A 
simple vaginal prolapse of any extent is, as has been stated, quite 
10 



146 PROLAPSUS VAGINA. 

rare. "When it does occur it generally affects the posterior wall, 
but prolapse, accompanied by hernia, is more commonly found 
to affect the anterior wall, cystocele existing. Should the case 
be complicated by vesical or rectal prolapse, the symptoms just 
enumerated will present themselves, with the addition of others 
dependent upon disturbance of the functions of the part which 
forms the hernia. In one case the concomitant symptoms will 
point towards the bladder ; in another, the rectum, and, in very 
rare instances, the small intestines. 

As the treatment of prolapsus vaginae is, with slight modifica- 
tions, the same for uncomplicated and complicated cases, it will be 
considered after the subject of vaginal hernias has been discussed. 

VAGINAL HERNIA. 

Cystocele. 

Cystocele, or vesico- vaginal hernia, consist^ of descent of the 
bladder towards the vulva, so as to impinge upon the vaginal 
canal. When the anterior wall of the vagina, which is closely 
adherent to the bladder, the base of which it sustains, ceases to 
afford the required resistance, the bladder descends and forms in 
the vagina a small pouch. This is at first very small, but gra- 
dually it increases, until at last it forms a decided tumor, which 
hangs between the labia majora. The pouch thus created becomes 
filled with urine, which, in the ordinary act of micturition, cannot 
be evacuated, from its being contained in a species of diverticulum. 
This undergoes decomposition, free ammonia is formed, and cys- 
titis or vesical catarrh is established, which annoys the patient 
by pain, heat, vesical tenesmus, and scalding in urination. Should 
any doubt exist as to the character of the tumor felt in the vagina, 
a curved sound or catheter may be passed into it for the settle- 
ment of the question. 

It is an interesting question whether cystocele is ever the cause 
instead of the result of prolapse of the vagina. It is probable that 
it may be so in very rare cases, though such a connection between 
the two affections must be uncommon, since the former seldom 
occurs except in women who have borne children, and thus been 
exposed to influences which tend to diminish vaginal resistance. 
Scanzoni 1 is convinced that the vesical prolapse is sometimes 

1 Op. cit., p. 497. 



EECTOCELE. — ENTEROCELE. 147 

primary, and due to irregular spasmodic contraction of the fibres 
of the body while the neck remains firm. This forces the urine 
to the fundus, which dilates and undergoes displacement. 

Rectocele. 
Eectocele, or recto-vaginal hernia, occurs in a manner similar, 
to that by which the bladder descends. The posterior wall of 
the vagina ceasing to give proper support to the anterior wall of 
the rectum, this forms a pouch which soon fills with fecal matters. 
The feces becoming hard, and, in consequence, irritating, create 
mucous inflammation and discharge, with tenesmus, obstinate 
constipation, and haemorrhoids. The tumor thus formed will 
sometimes equal in size a man's fist, and protruding over the 
perineum give some difficulty in diagnosis from its size and 
solidity. This difficulty would at once disappear upon rectal 

exploration. 

* 

Enter ocele. 

Enterocele, or entero-vaginal hernia, consists in descent of a 
portion of the small intestines into the pelvis, so as to impinge 
upon the vaginal canal. Such a descent usually occurs in this 
manner : a loop of intestine resting in Douglas's cul-de-sac stretches 
this serous prolongation, and, advancing between the rectum and 
vagina, pushes the posterior wall of the latter before it so as to 
form a tumor at the vulva. In a similar manner it is stated that 
the intestine may advance between the bladder and uterus and 
depress the anterior vaginal wall, but this must be rare, as authors 
of extensive experience assert that they have never met with it. 

Enterocele is not an accident likely to produce evil results 
unless it occur during labor, when strangulation may take place. 
Even at this time such an instance is very rare, for the free passage 
afforded the displaced intestine back to the abdomen will almost 
always preclude this difficulty. Dr. Meigs 1 relates a case occur- 
ring during labor, in which the progress of the parturient process 
was checked by a large mass of intestines until he succeeded 
in reducing the hernia. He says, with reason, that in such a case 
strangulation or contusion was to have been feared. 

One very momentous aspect in which these hernia: must be 

1 Notes to Colombat, p. 211. 



148 PKOLAPSUS VAGINA. 

viewed is in relation to puncture of vaginal tumors, occurring 
during labor, for ascertaining their contents. Wo such explora- 
tive means should be resorted to without careful exclusion of 
vaginal hernias of all descriptions, and especially of that of which 
we have last spoken. The peculiar sensation to the touch, of 
'a tumor filled with air, a resonant sound upon percussion, the 
detection of peristaltic movements, and careful exclusion of all 
other forms of tumor which might appear under the circum- 
stances, will serve to avoid error. 

Treatment of Prolapsus Vaginse and its Complications. — Should 
the accident have occurred suddenly, reduction should at once be 
accomplished, and the recurrence of the displacement prevented 
by appropriate means. The bladder and rectum being evacuated, 
the patient should be placed in the knee-elbow position, and, the 
fingers being well oiled, steady pressure should be exerted in coin- 
cidence with the axis of the inferior strait, until the prolapsed 
part is returned to its place. In the case of enterocele already 
referred to as treated by Prof. Meigs, the patient was placed upon 
the left side, and taxis being practised, the mass suddenly slipped 
above the superior strait, into which the next uterine contraction 
forced the child's head. To prevent a relapse the pelvis should 
be elevated, the patient kept perfectly quiet, tenesmus, if present, 
relieved by the use of opium, and the vagina constricted by astrin- 
gent injections. 

But sudden cases of vaginal prolapse and hernia are very rarely 
met with. It is usually those which have slowly and gradually 
established themselves that we are called upon to treat, and these 
are always obstinate and rebellious. The means at our command 
for overcoming such cases are the following : — 

1st. Local astringents and tonics; 

2d. Supplementary support ; 

3d. Surgical procedures. 
The first of these may be effectual in slight cases, but in those 
of graver character it will very generally prove insufficient. The 
tone and strength of the vagina may be temporarily restored by 
the use of injections of large amounts of cold water medicated 
with tannin, alum, iron, or zinc, employed night and morning. 
The patient should be sent during the summer to a watering- 
place, where sea-bathing and injections of sea- water into the 



TREATMENT, 



149 



vagina may be employed. A very excellent result will also 
sometimes follow the use of vaginal suppositories containing one 
of the astringents mentioned. 

Supplementary Support may be effected by an abdominal sup- 
porter, with perineal band, and by the use of a properly con- 
structed pessary, such, for example, as the double lever of 
Hodge, the ring of Meigs, or the stem of Cutter. 

Fig. 35. 





Abdominal supporters. (Brown.) 



In some instances the air pessary of Gariel will be found to be 
very useful, more especially where the bladder or rectum partici- 
pates in the prolapse. But this must necessarily be only palliative 
in its results, since while it relieves the immediate consequences 
of want of power in the canal, it increases the existing weakness 
by continued distension. 

Surgical Procedures. — Of these there are three which may prove 
effectual. If a ruptured perineum seem to produce the want of 
power, the operation of perineorrhaphy may be all that will be 
necessary. This is described on page 115. In a certain number 
of cases where the vaginal displacement has not resulted in pro- 
lapse of the uterus, and where from the advanced age of the patient 
patency of the vagina is no longer necessary, union of the labia 
majora for the lower three-quarters of their extent may fulfil the 
indication. This operation, inaugurated by Vidal de Cassis and 
subsequently essayed by many others throughout Europe, con- 
sists in paring the edges of the labia majora, removing the labia 



™^™ 



150 PROLAPSUS VAGINA. 

minora, and uniting the vivified surfaces by silver sutures. I 
cannot lay the steps more clearly before the reader than by 
giving the account of a successful case by Dr. Schuppert, of N. O. 
His operation was performed for complete closure of the vulva, 
and extended higher up than would be necessary in the case we 
are supposing. 

" The woman was placed on her knees, whilst her abdomen, 
chest, and head were supported by pillows. In paring the inner 
part of the labia majora, removing the nymphse to a level with 
the denuded surface of the labia majora, and vivifying a circular 
part of the entrance of the vagina to an extent of two centimetres, 
I had obtained a surface which, when agglutinated, would measure 
from four to five centimetres in depth. Entering now the long 
flexible needle from outside the lower vivified border of the right 
labium majus, in a horizontal line with the meatus urinarius, I 
thrust it in and back through the tissues, till its point came out 
in the centre of the posterior wall of the urethra, just above the 
meatus urinarius. A silver wire was then introduced into the 
eye-hole of the needle and the latter withdrawn, leaving the other 
end of the wire in the vagina. The needle, freed from the thread, 
was then inserted again in the left labium majus in a correspond- 
ing place with that of the right labium, thrust through the tissues, 
and brought out at the same point where the wire was hanging 
out of the urethral wall. This end of the wire was now carried 
through the eye-hole of the needle. In withdrawing the latter, I 
had formed a loop which, when tightened, would include a depth 
of at least four centimetres. Three sutures were in this manner 
applied, each of them going through the posterior wall of the 
urethra. The other four sutures were placed at proper distances, 
reaching on each side above the denuded surface of the vagina. 
All the sutures were then secured outside the labia majora, over 
broad leaden clamps, by perforated shot." 

But if prolapsus uteri has occurred, or even a marked degree 
of vesical or rectal displacement, the operation of elytrorrhaphy, 
or diminishing the calibre of the vagina, is the only procedure 
upon which reliance can be placed. This operation will be fully 
described in connection with prolapsus uteri. 



CHAPTER X. 

FISTULA OF THE FEMALE GENITAL OEGANS. 

Definition. — As a result of certain traumatic and morbid pro- 
cesses, the continuity of the vaginal and uterine walls may be 
destroyed and communication established with adjacent viscera. 
To the tracts or passages thus opened, the name of fistulas has 
been given. 

Varieties. — These communications connect the vagina with some 
viscus in immediate proximity, for the natural outlet of which 
they act vicariously, or with some neighboring part, as the peri- 
toneum, the vulva, or the pelvic areolar tissue. Their varieties 
have received the following descriptive appellations : — 

Urinary Fistulse. 

Yesico-vaginal fistula ; 
Urethro-vaginal fistula ; 
Yesico-utero-vaginal fistula ; 
Yesico -uterine fistula. 

Fecal Fistulee. 

Recto- vaginal fistula ; 
Entero-vaginal fistula ; 
Recto-labial fistula. 

Simple Vaginal Fistulx. 

Peritoneo-vaginal fistula ; 
Perineo-vaginal fistula ; 
Blind vaginal fistula. 

Ueinaky Fistula. 

Urinary fistulas may occur on any part of the anterior surface 
of the genital canal intervening between the vulva and fundus 



152 FISTULA OF THE FEMALE GENITAL ORGANS, 

Fig. 36. 

- 




Varieties of vesical fistulas : 1. Urethro vaginal fistula; 2. Yesieo-vaginal fistula; 
3. Vesicouterovaginal fistula ; 4. Vesico-uterine fistula. 

uteri. Fig 36 displays the points at which they are usually ob- 
served. 



Vesico- Vaginal Fistula (2) is a communication between the 
bladder and vagina, either at the trigone or the bas-fond, which 
may involve only enough tissue to admit a small probe, or en- 
tirely destroy the vesico-vaginal wall. Such an opening may be 
oval, angular, elliptical or linear in shape, and its borders may be 
thick or thin, soft or indurated, rough or smooth, pale or vascular. 

Urethro- Vaginal Fistula (1) resembles that just mentioned, ex- 
cept in the fact that the destruction of tissue which has produced 
it involves the wall of the urethra, and not that of the bladder. 

Vesico- Uterine Fistulse (4) are those in which there is a direct 
communication between the bladder and uterus above the point 



URINARY FISTULA. 153 

of vaginal attachment. The vagina is consequently not involved, 
and the urine passing into the uterus escapes at the os. 

Vesico- Utero- Vaginal Fistulee (3) are those in the production of 
which a lesion occurs in both uterus and vagina, as is imperfectly 
shown by (8). At the vaginal junction there is a perforation 
of the bladder, but this does not penetrate to the cavity of the 
uterus. A canal is created in its wall, and through this the urine 
escapes into the vagina. The last two forms of fistulas were first 
accurately described by Jobert, who made of the last, two varie- 
ties, superficial and deep. In the first a canal is channelled out 
on the vesical surface of the cervix uteri ; in the second, the cer- 
vix is to a greater or less extent destroyed by the process of 
sloughing, and through it the urine passes. In the first form the 
lesion is chiefly vesical and uterine, the vagina not being much 
injured ; in the other it affects three organs, the bladder, the 
uterus, and the vagina. All these forms of fistulas have thus 
been grouped into classes by Dr. Bozeman : — 

1st Class. Those consisting in a communication between the 
urethra and vagina ; 

2d Class. Those established at the expense of the trigonus 
vesicalis ; 

3d Class. Those situated in the bas-fond of the bladder ; 

4th Class. Those involving the trigone and root of the urethra, 
the trigone and bas-fond, or all three of these parts together ; 

5th Class. Those complicating the cervix uteri. 

In some cases, however, multiple fistulas exist, and no special 
classification can be made. 

Causes. — Any influence which is capable of destroying the 
continuity of the vaginal walls, either by mechanical, chemical, 
or vital action, would of course give rise to this condition. Those 
which are found in actual practice to have proved efficient, are 
the following : — 

1st. Prolonged or very severe pressure ; 

2d. Direct injury; 
. 3d. Ulceration or abscess. 

Pressure, which is more frequently a cause than any of the 
others mentioned, is generally produced by the child's head re- 



154 FISTULA OF THE FEMALE GENITAL OEGANS. 

maining too long in the pelvis during labor. This is beyond all 
doubt the most prolific source of the accident, though it may 
also attend a rapid labor in which the vagina has been pressed 
against some point of the pelvis with great violence. Such pres- 
sure produces sloughing of the part of the vagina which receives 
it, and at that spot a deficiency of tissue in future exists, which 
constitutes a fistula. The process of sloughing occurs from 
pressure of the foetal head, exactly as a bedsore takes place in 
one who lies for too long a time in the same position, the sequence 
being, disturbed and retarded circulation, impaired nutrition, and 
local death. Or a puerperal vaginitis may be established, which 
runs a violent course, and may end in sloughing at the end of 
several weeks. 

An involuntary flow of urine usually announces the existence 
of a fistula within three or four days after delivery, though when 
it is the result of injury inflicted by instruments employed in 
delivery, it may occur immediately. On the other hand, the 
separation of the slough, which will entail deficiency of tissue 
and its results, may not take place until much later, when per- 
haps all fears are allayed, and the case is regarded as progressing 
favorably. Jean Louis Petit records one case developing its 
symptoms after a month ; Jobert one in which on the twenty- 
second day after delivery the slough was found at the mouth of 
the vagina ; Adier, of Iowa, one in which after twenty-nine days 
the slough was only partially separated ; and Agnew, of Phila- 
delphia, another, in which it occurred on the twenty-first day. 

Other agencies which may act in the same manner, but which 
have been rarely noticed, are pessaries, stones in the bladder, 
fecal accumulation, &c. 

Direct injury may produce the accident by contusing or lace- 
rating the vaginal walls, as may occur during delivery by the 
forceps or craniotomy. That these operations when carelessly or 
unskilfully performed may produce a fistula, no one will pretend 
to deny, but there can, with the evidence now recorded, be no 
doubt that they have often been credited with unfortunate results 
which were in reality due to tardiness in their employment. Yery 
often, where a labor has been allowed to be prolonged in the 
second stage until the vitality of certain points in the vagina has 



UKINAEY FISTULA. 155 

become irremediably impaired, and the process of sloughing been 
absolutely inaugurated, delivery by forceps or craniotomy has 
been regarded as producing fistula. Under such circumstances 
the real morbid agency, prolonged and violent pressure, is lost 
sight of, and the more palpable agents, the instruments employed, 
are viewed as the source of the accident. The truth with refer- 
ence to this point should be well understood by every practitioner, 
for unless it be so, an incompetent person may shield himself from 
merited blame by casting it upon a consulting physician by whose 
efforts the lives of both mother and child have been saved, or a 
skilful operator may suffer unjustly in a suit for mal-practice. 

In a report upon this subject by Dr. I. Baker Brown 1 to the 
Obstetrical Society of London, in 1863, the following statements 
are made: "With regard to the causes of vesico- vaginal fistula, 
of the 58 cases admitted into the London Surgical Home 47 were 
over 24 hours in labor, and 39 were as much as 36 hours or more ; 
7 were two days ; 16 were three days ; 3 were four days ; 2 were 
five days ; 2 six days ; and 1 seven days. 

" In the whole number of cases instruments were used in 29, 
exactly one half, and in 4 only of these was the labor less than 
twenty-four hours, and with seven exceptions the patient had 
been thirty-six hours or more in labor before instruments were 
used. 

"Of the 58 cases in 24 only the injury happened at the first 
labor ; in 7 at the second ; in 5 at the third ; in 4 at the fourth ; 
in 6 at the fifth ; in 2 at the sixth ; in 5 at the eighth ; in 1 at the 
ninth ; 1 at the thirteenth ; 1 at the fifteenth ; and 2 not men- 
tioned." 

" From the foregoing statistics it is evident that the cause of 
the lesion is protracted labor, and not from the use of instruments 
or deformity of the pelvis." 

"As a necessary deduction from what has been stated, it follows 
that vesico-vaginal fistula would scarcely or never occur, if a 
labor were not allowed to become protracted ; and this is a point 
for the careful consideration of practitioners in midwifery." The 
experience of Drs. Sims, 2 Emmet, and Bozeman 3 is confirmatory 

1 Obstet. Trans., vol. v. p. 28. 

2 Gardner's Notes to Scanzoni, p. 503. 

3 Agnew. Vesico- Vaginal Fistula. 



156 FISTUL-E OF THE FEMALE GENITAL ORGANS. 

of that of Dr. Brown, and as the opportunities for observation 
enjoyed by these four practitioners have probably been as ex- 
tensive as those of any living authorities, their evidence may be 
regarded as conclusive. 

Ulceration or Abscess. — The vaginal walls may be eaten through 
by cancerous, syphilitic, or phagedenic ulcers, or a communication 
may be established by an abscess opening into the vagina and a 
neighboring viscus or part. In one case I found, in the autopsy 
of a woman who had died from a profuse diarrhoea, in which the 
feces had passed by the vagina, a communication created by 
abscess between the caput coli and that canal. 

Cancerous disease often destroys the vesico-vaginal septum, but 
as these fistulas are irremediable, and attend upon a rapidly fatal 
disorder, they attract little attention in themselves. Lastly, cer- 
tain diseases producing deficiency of nutrition, as, for example, 
the continued fevers, may cause sloughing of the vaginal walls 
or phagedenic ulceration. 

Symptoms. — The prominent symptoms and signs of urinary fis- 
tulas may be grouped under three heads : first, those furnished by 
a characteristic discharge ; second, those arising from the irritant 
action of such discharge upon the part over which it flows; and 
third, those afforded by physical examination. 

Sometimes the escape of urine is so excessive as to preclude 
the necessity of a discharge per vias naturahs ; at others the ex- 
cretion is partly evacuated by the natural and partly by the vica- 
rious outlet. This symptom shows at times eccentric variations. 
"When the fistula is seated in the urethra the bladder may be dis- 
tended without loss, which may take place into the vagina during 
micturition. Sometimes while in the horizontal posture the escape 
will cease, the anterior vesical wall being pressed by the intestines 
against the bas-fond so as to close the opening, and in other cases, 
where the fistula is above the orifice of the ureters, the flow will 
take place while the patient lies, and cease when she stands. 

The passage of excrementitious material through a canal and 
over a tissue not intended by nature to tolerate it, produces inflam- 
matory action, pruritus, eruptions and excessive irritability. In 
urinary fistulas the vulva and thighs are usually red, excoriated, 



PHYSICAL SIGNS. 157 

and covered by a vesicular eruption. The vagina is sometimes 
covered by urinary concretions, and from the patient's body 
emanates a highly offensive odor, which, to one accustomed to 
seeing the condition, is often sufficient for purposes of diagnosis. 
The general health of the patient is very likely in time to give 
way, and hysteria, chlorosis and graver disorders often show 
themselves. 

Physical Signs. — If the fistulous orifice is a large one, even a 
superficial examination by touch, the patient lying upon her back, 
will generally serve to reveal the nature and extent of the lesion. 
It is different, however, with very small fistula?, which will some- 
times elude the most careful investigation. For their detection 
Sims's speculum should be employed, and in many cases it will be 
found advisable to place the woman in the knee-elbow position, 
instead of that on the side, before its introduction, and to have the 
buttocks and labia pulled apart by the hands of assistants. Even 
this method is not effectual in revealing the difficulty if the open- 
ing be very minute. Under these circumstances the bladder 
should be injected with water and its escape into the vagina care- 
fully watched for. Sometimes, by this means, a capillary opening 
just at the junction of the vagina and cervix will be detected. 
Kiwisch, Meyer, Yeit, and others have used for this purpose 
water colored with substances which will impart a bright tinge 
to it. Infusions of cochineal, madder, or indigo may be thus em- 
ployed. The opening being once detected, the probe and finger 
will readily reveal the course, extent, and terminus of the tract. 

Complications. — The complications which these fistulas deve- 
lop are vaginitis, vulvitis, stricture of urethra and vagina, and 
sometimes endo-metritis and peri-uterine inflammation. The most 
constant and important of these is the formation of bands, which 
contract the vagina, and which often require severance before 
operative procedure can be practised. 

Prognosis. — Previous to the year 1852 the prognosis of all 
cases in which the orifice acted as a vicarious outlet, for example. 
vesico- vaginal, recto- vaginal, and vesico-utero- vaginal fistula: was 



158 FISTULJS OF THE FEMALE GENITAL ORGANS. 

eminently unfavorable, for they very rarely undergo spontaneous 
recovery, and the means of cure at our command up to that time 
were uncertain and full of discouragement. In 1860 Dr. Sims 1 
stated, "Of 261 cases of vaginal fistula (vesical and rectal) 216 
have been permanently cured by the silver wire suture ; 36 are 
curable and 9 incurable. Every case is curable where the opera- 
tion is practicable, provided there is no constitutional vice to 
interfere with the powers of union. Success is the rule, failure 
the exception." 

The enlarged experience of the profession has fully corrobo- 
rated these assertions, made seven years ago, and it may now be 
accepted as a true statement as to the prognosis of all fistulse of 
the female genital organs except cases of vesico-uterine variety, 
in which the point of rupture is out of reach of surgical interfer- 
ence. 

History. — The history of this subject dates back only to 
the sixteenth century, when attention was called to it, and a 
plan of treatment proposed by Ambrose Pare. Before the dis- 
covery of the forceps the accident must have been one of very fre- 
quent occurrence, for then powerless labor was not under the con- 
trol of the obstetrician, except by a resort to a set of badly con- 
structed instruments for craniotomy, which in themselves presented 
serious dangers of laceration. The symptoms which mark its exist- 
ence are so palpable and distressing that it does not require a physi- 
cian to diagnosticate it, and no case of any gravity could have 
escaped notice. And yet, curious to relate, there are few diseases 
to which woman is liable, which have received so little notice 
at the hands of the ancients. Even pelvic cellulitis and other 
affections which have but lately attracted attention from the phy- 
sicians of our day are distinctly spoken of by the writers of the 
Greek school ; but this one, so annoying, so destructive of happi- 
ness, and so urgent in its demands for relief, has received scarcely 
any mention. It is true that Hippocrates makes some slight allu- 
sion to involuntary discharge of urine following difficult labors, 
but his remarks upon the condition are meagre and unimportant. 

I do not claim to have made a full examination of the writings 

1 Gardner's Notes to Scanzoni, p. 515. 



HISTORY. 159 

of the Greeks and Komans with reference to the subject, but base 
the statement which I have advanced chiefly upon the fact that 
the two great compilers of their period. Aetius and Paulus iEgi- 
neta, make no mention of it. The work of Aetius upon diseases 
of women (Tetrabiblos IY.) is made up of quotations from Sora- 
nus, Aspasia, Galen, Philumenus, Archigenes, Leonidas, Eufus, 
Philagrius, Asclepiades,* in fact of all worthy of note whose writ- 
ings were stored in the Alexandrian Library, which was the seat 
of his labors. By none of these is mention made of the affec- 
tion. The works of Paul of JEgina, enriched as they have been 
by the copious notes of Dr. Adams, their translator, are equally 
silent; and the researches of those who have examined the 
writings of the Arabians announce no discovery of any descrip- 
tion of it at their hands. At any rate, it is quite certain that no 
contributions to the treatment of the difficulty were made by the 
writers of the Greek, Eoman, or Arabian schools. 

Beginning at the seventeenth century, I will allude only to 
those who have made some advance in treatment, and not en- 
deavor to record the names of all who have reported cures, or 
advised procedures which have not been of subsequent utility. 

Before proceeding upon the historical sketch which ensues I 
would draw the attention of the reader to two interesting facts 
which it will demonstrate. It will be seen that for centuries steady, 
persevering, and systematic efforts have been made to render this 
revolting malady curable, and as has so often been the case in 
other great discoveries, the minds of several investigators pursued 
the same course until at last success was reached. After a disco- 
very has been made it is always easy to point out the elements 
upon which it rests for its success,' and even to follow the process 
of reasoning by which each in turn was supplied. There can be 
no question that the three elements necessary for successful treat- 
ment of the lesion which we are considering, were : — 

1st. A means for exposing the fistula to view and manipula- 
tion ; 

2d. A suture which would remain in place without causing in- 
flammation ; 

3d. A means of disposing of the urine during the process ot 
cure. 

From the time that Pare suggested a plan of treatment, it will 



160 FISTULA OF THE FEMALE GENITAL ORGANS. 

be noticed that surgeons brought these three means of cure to 
their aid. But they employed them separately, some using one 
of them, some another, and others still combining two. It was 
not, however, till the time of Gosset, in 1834, that the three were 
combined by the same operator. 

In 1570 Ambrose Pare proposed the closure of vesico-vaginal 
fistulas by a retinaculum. In 1660 Koonhuysen, of Amsterdam, 
used a speculum, through which he pared the edges of flstulae, 
and united them by a needle. In 1720 Vcelter, of Wurtemburg, 
advised a needle, needle holder, suture by silk or hemp, and a 
catheter. In 1804 Desault used a vaginal plug and catheter in 
the bladder. In 1812 Naegele, of "Wurtemburg, scarified the 
edges by scissors, used needles to approximate them, and em- 
ployed the interrupted suture. In 1817 Schreger, of Germany, 
placed the patient on the abdomen, scarified and used interrupted 
suture. In 1825 Lallemand, of France, applied nitrate of silver 
to the edges of the fistula, and approximated them by a " sonde 
erigne" passed through the bladder, and, of fifteen cases, cured 
four. In 1829 Eoux, of France, tried twisted suture with metallic 
bars and ordinary thread. In 1834 Gosset, of London, combined 
the knee-elbow position, levator perinei speculum, metallic 
sutures, and catheter permanently kept in the bladder. In 1836 
Beaumont 1 employed the quilled or clamp suture. In 1837 Jobert 
de Lamballe resorted to autoplasty, transplanting a piece from 
the labia, buttocks, or thighs. In 1838 Wutzer, of Bonn, placed 
his patients on the abdomen, pared the edges of the fistula, and 
approximated them by insect needles and figure of 8 suture. To 
expose the fistula the perineum was held up by a hook and the 
labia drawn aside by assistants. In 1839 and 1840 Hayward, of 
Boston, U. S., reported three cases cured by vivifying the edges 
and closing with silk suture. This surgeon introduced a notable 
improvement, and aided in the final success by vivifying not only 
the borders of the fistula but the neighboring vaginal surfaces. 
In 1844 Chelius 2 placed his patients in the knee-elbow position. 
In 1846 Metzler, 8 of Prague, employed the levator perinei specu- 
lum, perforated balls the size of shot, the knee-elbow position, 

' Med. Gaz., Dec. 3d. 1836. p. 355. 2 Agnew, op. cit., p. 15. 

3 Sohuppert on Ves.-Vag. Fistula, p. 41. 



HISTOKY. 161 

gilded needles, and a permanent catheter. In 1847, Mettauer, of 
Virginia, employed the catheter and leaden sutures with such 
success that he was led to make the following statement : " I am 
decidedly of the opinion that eYery case of vesico-vaginal fistula 
can be cured, and my success justifies the opinion." In 1852, 
Jobert de Lamballe adopted his method styled, "reunion autoplas- 
tique par glissement," which consisted in giving sufficient vaginal 
tissue for union, by cutting transversely through the vagina, at 
its junction with the uterus, in a line with the fistula. In 1852, 
Marion Sims, 1 of Alabama, combined the three essentials for 
success, the speculum, the suture, and the catheter, and placed 
the operation at the disposal of the profession. 

The discoveries to which he laid special claim were these : — ■ 

1st. A method by which the vagina could be distended and 
explored ; 

2d. A suture not liable to excite inflammation or ulceration ; 

3d. A method of keeping the bladder empty during the process 
of cure. 

From a study of the literature of this subject it is made as 
evident as written testimony can make any history of the past, 
that not only did several investigators combine two of these 
elements of success in their operations, but that two, Gosset, in 
England, and twelve years afterwards Metzler, in Germany, 
absolutely combined all three. It is also made equally evi- 
dent that they failed to recognize the importance of what they 
had attained, and did not impress its value upon others, so that 
humanity could profit by it. Dr. Gosset's procedure is thus 
described in his own words in the first volume of the London 
Lancet, page 346. 

" Having placed the patient resting upon her knees and elbows 
upon a firm table of convenient height covered with a folded 
blanket, the external parts were separated as much as possible by 
a couple of assistants, so as to bring the fistula, which was imme- 
diately above the neck of the bladder, into view. I seized with 
a hook the upper part of the thickened edge of the bladder which 
surrounded the opening, and proceeded with a spear-shaped knife 
to remove an elliptical portion, which included the whole of the 

1 Ainer. Journ. Med. Sci., 1852. 
11 



162 FISTULA OF THE FEMALE GENITAL ORGANS. 

callous lip surrounding the fistula, the long angle of the ellipsis 
being transversely. This was readily effected; but, in conse- 
quence of the very contracted state of the parts, the next steps 
of the operation were with difficulty executed ; and I should not 
have succeeded in passing the sutures, had I not used needles 
very much curved, and a needle holder, which I could disengage 
at pleasure, the needles being withdrawn with a pair of dissecting 
forceps after the holder was removed. In this way three sutures 
were passed ; and afterwards, by twisting the wire, -the incised 
edges were brought into contact and retained in complete apposi- 
tion until they had firmly united. One of the sutures was re- 
moved at the end of the ninth day, the second at the end of the 
twelfth day, and the third was allowed to remain until three 
weeks had elapsed. After the operation the patient was put to 
bed and desired to lie on her face, an elastic gum catheter, 
having a bladder secured to its extremity for the reception of the 
urine, having been introduced and retained by means of tapes. 
She had not the slightest discharge of urine through the vagina 
after the operation, which completely succeeded in restoring the 
healthy functions of the part. The advantages of the gilt wire 
suture are these : It excites but little irritation, and does not 
appear to induce ulceration with the same rapidity as silk or any 
other material with which I am acquainted; indeed, it produces 
scarcely any such effect, except when the parts brought together 
are much stretched. You can, therefore, keep the edges of a 
wound in close contact for an indefinite length of time, by which 
the chances of union are greatly increased. I have used it now 
in very many operations, as after extirpation of the breasts, 
tumors of various kinds, and for bringing the lips together after 
the removal of a cancerous growth, in all of which cases it 
answered extremely well." 

The method of Metzler was published in the Prague Viertel 
Jahresschrift for 1846, under the title of "Pathology and Treat- 
ment of Urinary and Yesico- Vaginal Fistulas, with a method of 
treatment easily executed and completely successful." I trans- 
cribe his article from the brochure of Dr. Schuppert already 
alluded to. 

"To perform the operation successfully, it is of much import- 
ance to have — 1st, a speculum, serving as a dilator of the vagina. 



HISTOEY. 168 

Such, an instrument consists of a grooved conical blade, five and a 
half inches long, three inches wide at the anterior part, one-half of 
an inch wide at the posterior. The end of the speculum is bent 
under at a right angle, and protected with wood for the handle. 
The instrument is best when made of silver, and polished to re- 
flect the light on the parts to be operated upon. 2d, an apparatus 
consisting of perforated clamps, gilded needles, and an instrument 
called " Kosenkranzwerkzeng," consisting of perforated balls of 
the size of large shot, by which the clamps are held in contact. 
After the patient is placed on her knees and elbows, the dilator 
is introduced into the vagina and given to an assistant, who in 
holding it presses it against the rectum. The edges of the fistula 
are then pared off, which may be accomplished with curved scis- 
sors. One line and a half from the mucous membrane of the 
vagina and half a line from the edge of the bladder have to be 
cut off; the needles are then applied, and the wound held in co- 
aptation by the clamps ; a female catheter is introduced into the 
bladder by the urethra, and the catheter fastened by a T bandage." 

From what has been said thus far it would appear that Dr. 
Sims was forestalled in all the details of the discovery by which 
he has rendered vaginal fistulas curable. To a certain extent this 
is unquestionably true, but only as regards the theory of the 
matter. Before his publications the unfortunate women whose 
lives were rendered miserable by fistulas through the vaginal wall 
were virtually almost as hopelessly affected as they were before 
Grosset and Metzler appeared in the field. 

Velpeau, 1 in 1839, thus speaks of cure of these fistuke : " To 
abrade the borders of an opening, when we do not know where 
to grasp them ; to shut it up by means of needles or thread, when 
we have no point apparently to secure them ; to act upon a mov- 
able partition placed between two cavities, hidden from our sight, 
and upon which we can scarcely find' any purchase, seems to be 
calculated to have no other result than to cause unnecessary suf- 
fering to the patient." Yidal de Cassis 2 says : "I do not believe 
that there exists in the science of surgery a well authenticated 
complete cure of vesico-vaginal fistula." Malgaigne, 3 in 1854, 

1 Operative Surgery. 2 Pathologie Exterue. 

3 Maiiuel de Med. Ope rat. 



164 FISTULA OF THE FEMALE GENITAL ORGANS. 

says : "But the truly rational method, that which at present offers 
the greatest facility and efficacy, and the only one which should 
be applied in all cases of fistula of large size, is the suture by the 
procedure of Jobert." 

This was the real state of science with reference to this oppro- 
brium chirurgiae when Marion Sims, by combining and utilizing 
the three essentials for success, gained it, and rendered the ope- 
ration practicable for all surgeons. It must not be supposed that 
he availed himself of the results obtained by his predecessors. 
All that he attained was arrived at by hard and original labor. 
Indeed, no one can read his address upon "Silver Sutures in 
Surgery," delivered before the New York Academy of Medicine, 
in 1857, without being struck by his want of familiarity with the 
antecedent literature of the subject of his discourse. 

Since the first publication of Sims's method, numerous modifi- 
cations of it have been put into practice both in this country and 
Europe, and Dr. Sims himself has altered his plan of operating 
very much. The principle which he demonstrated is, however, 
the same, and the modifications of the operation all act in develop- 
ing it. 



Means for Obtaining a Natural Cure. — Within a few days after 
delivery the obstetrician is generally made aware of the existence 
of vesico- vaginal fistula by a steady and involuntary dripping of 
urine. As soon as this is evident a Sims's -stationary catheter 
should be placed in the bladder, the vagina frequently syringed 
out with warm water to lessen inflammatory action, and the 
patient kept perfectly quiet in order that a repair of the injury 
may be accomplished by the efforts of nature. This is all that 
can be done at this time, for it is too early to resort to suture, and 
the lochial discharge would be interfered with by a tampon in- 
tended to aid in the cure. The operation by suture should not 
be undertaken before the immediate results of parturition have 
passed off and the fistula has assumed a permanent size and 
character. 



treatment. 165 

Treatment. 

The methods at our command for curing, or at least obviating 
the inconveniences due to fistulas of the female urinary apparatus, 
are — 

1st. Cauterization ; 

2d. Suture ; 

3d. Elytroplasty ; 

4th. Occlusion of the vagina or uterus. 

Cauterization. 

This once favorite method of treating all varieties of these fis- 
tulas has now almost entirely fallen into disuse under the influence 
of improved methods by suture. Malgaigne probably gives this 
means its proper place when he declares that it should be em- 
ployed only in those cases where the fistula is scarcely perceptible. 
Even in such cases Sims's operation is far preferable, and cauteri- 
zation should be employed only where some special circumstance, 
such as want of skill or of the proper instruments, forces the 
operator to resort to it. The performance of it is very simple. 
Sims's speculum being passed so as to expose the fistulous spot, 
its borders should be thoroughly touched with a pointed stick of 
nitrate of silver or the actual cautery. This should not be re- 
peated before the slough created has separated, and an opportunity 
been allowed for granulation to fill up the opening. 

To check the flow of urine through the fistulous orifice and 
support the vaginal and vesical walls during the process of granu- 
lation, a small tampon of cotton, a Gariel's air pessary, or a glass 
vaginal plug, like that delineated at Fig. 31, should be kept in 
the vagina, and, to prevent distension of the bladder, a Sims's 
catheter should be permanently retained. 

Suture. 

Preparation of the Patient. — No operation in surgery more 
urgently demands a good constitutional condition, as an element 
of success, than this. Should the patient's health not be good, 
and her blood- state be abnormal, a visit to the country, exercise, 
and fresh air, with vegetable and mineral tonics, will do a great 



166 FISTULA OF THE FEMALE GENITAL ORGANS. 

deal towards avoidance of failure. At the same time the vagina 
should be regularly syringed with warm water to overcome local 
inflammation, and insure cleanliness. Should the disorder which 
caused the destruction of the vaginal wall have produced as 
a complication cicatricial bands in the canal, these should be 
cut, from time to time, and allowed to heal over a glass vaginal 
plug, and if contraction have taken place in the urethra, it 
should be overcome by bougies. Before the time of the opera- 
tion the bowels should be thoroughly emptied by a cathartic, and 
on the day of its performance very little food should be taken, for 
fear that the long-continued use of an anaesthetic might produce 
vomiting, which would tear out the sutures. 

Sims' s Operation. — This operation may be divided into three 
parts : — 

1st. Paring the edges of the fistula ; 

2d. Passing sutures through them ; 

3d. Approximating them and securing the sutures. 
The patient being placed upon a table two and a half by four 
feet, which is covered by folded blankets, is brought under 
the influence of an anaesthetic, and placed in the following posi- 
tion. She is made to lie on the left side, with the thighs bent at 
about right angles with the pelvis, the right a little more flexed 
than the left. The left arm is placed behind her back, and the 
chest brought flat down upon the table so that the sternum may 
touch it. The assistant, who is to hold the speculum, which is 
now introduced, does so with the right hand, while with the left 
she elevates the right side of the nates. The table should be so 
arranged that a bright and steady light may fall into the vagina, 
which being now fully distended, will be seen throughout its 
extent, except where it is obscured by the speculum. 

The operator having near him all the instruments, &c. which 
he will require, places his assistants thus : one holds the spec- 
ulum, another administers the anaesthetic, and a third stands 
ready at his right hand to remove the blood accumulating in 
the vagina, by means of sponges, in the sponge-holders, Fig. 42, 
which are rapidly washed in a basin of water that stands by his 
side, to be used again. A fourth, if attainable, may be well em- 



TREATMENT. 167 

ployed in handing the instruments as they are required. All 
being ready, he now proceeds with the first step of the operation. 

Paring the Edges of the Fistula. — The edge of the fistula at the 
point which is deemed most difficult of access and manipulation, 
is caught by the tenaculum and held up. Then, with a pair of 
long-handled scissors, Fig. 37, or a knife, Fig. 38, a strip is cut, 
extending from the mucous membrane of the bladder to that of 
the vagina, care being taken not to wound the former. 

Fig. 37. 




Long-handled scissors. 
Fig. 38. 



Bistoury for paring edges of fistula. 



Another portion of the edge is then seized, and removed like 
the first. The wound thus left should be one bevelled from the 
vesical surface outwards, and great care should be observed to 
remove the entire border, for upon this success depends. 

It is of great moment that sufficient tissue should be removed, 
and that the amount taken on the vaginal surface should be 
greater than that near the vesical. Prof. Simpson 1 makes this 
point very clear by the following language : " Enter the point of 
your knife into the vaginal mucous membrane at some distance 
from the fistula ; then transfix with your knife the edge of the 
fistula to the extent you intend to remove it, and, bringing it out 
at the vesical border, carry it right and left fairly round the open- 
ing, so as, if possible, to bring- out a complete circle of tissue." 

The tissue, from the edge of the fistula to the point of vaginal 
section, should measure at least four lines, one-third of an inch, 
while above, it should just touch the vesical border, not wounding 
its mucous membrane. This is made evident by Fig. 40. Par- 
ing this part of the operation the sponges, held in long-handled 

1 Diseases of Women. 



168 FISTULA OF THE FEMALE GENITAL OKGANS. 
Fig. 39. Fig. 40. 

a 
h 




Paring the edges. (Wieland and Dubrisay.) 



\ 



Showing bevelling of edges, a, 
vesical border ; b, vaginal bor- 
der ; c c, incision. 



Fig. 41. 




Sims's sponge-holder with handle 
nine inches long. (Sims.) 



sponge-holders, will have to be freely resorted to, but the bleed- 
ing generally soon ceases, and the operator may proceed to the 
second step. 



TREATMENT, 



169 



Passing the Sutures. — The sutures are passed by means of 
slightly curved needles held in a pair of strong forceps, Fig. 42, 
made for the purpose. In some cases the metallic thread, made 
of annealed silver, which is employed, may be passed at once, but 
usually silk threads are first passed, and then the silver sutures 
are attached and drawn through. The needle, held in the grasp 
of the needle-holder, should be passed at the angle of the wound 
which is most difficult of access, half an inch from the edge of the 
incision, and brought out at the vesical surface, but not involving 
its mucous lining. Fig. 43 represents the points of entrance and 
exit of the needle. 

The point of the needle having passed out, it is engaged by the 



Fig. 42. 




Course of the needle, a, vesical border; b, vaginal 
border ; c, point of entrance of needle ; d, point 
of exit of needle. 



& 




Passing the needle. (Wieland and Dubrisay.) 
Fig. 45. 



Needle held in forceps. 



Forceps for drawing needle. 



170 FISTULA OF THE FEMALE GENITAL ORGANS. 

small, blunt hook, Fig. 49, until it can be seized and drawn 
through by the needle forceps, Fig. 45. Then it is plunged into 
the other lip and drawn out half an inch from the edge of the 
incision. The ends of the silk suture are now given into the 
charge of the assistant holding the speculum, and another is passed 
in the same way about two lines, one-sixteenth of an inch, from 
the first. In this way a sufficient number is passed to close the 
fistula, Fig. 46. 

During this procedure the edge of the fistula is to be fixed by 
the tenaculum, and should firm, opposing force be needed to 
make the needles pass, it may be given by that instrument. 

When the needle is seized by the forceps and pulled so as to 
make the thread follow it, some opposing force is needed, or the 
thread might cut through the tissues. This force is offered in the 
species of fork represented in Fig. 47, which is put as a fulcrum 



Fig. 46. 



Figs. 47. 48. 49. 




1 



Twisting the sutures. 



Fulcrum for supporting wire while it is 
twisted. Fork with blunt points to aid 
the passage of sutures. Hook for en- 
gaging needle. 



under the thread at its point of exit, and made to sustain and 
draw it through. 

A bit of silver wire about twelve inches long is attached, by 



TREATMENT. 171 

bending its extremity, to the first silk suture, and by the use of 
the fork just mentioned, the silk thread is drawn through so as to 
make the silver replace it. The silk is then cut off, the silver 
suture put aside, and the operator proceeds to replace each silk 
thread in the same way. This being accomplished, the instru- 
ments are now changed in order to effect the twisting of the 
sutures. 

The ends of the silver sutures being drawn together by the 
fingers, and the edges of the wound carefully approximated, each 
thread is slightly twisted so as to keep the whole in apposition. 
Then the ends of the first suture are seized in the bite of the 
forceps, Fig. 46, slipped into the fulcrum, Fig. 47, and torsion 
is made so as to close the wound completely at this point. In 
this way the sutures are, one after the other, twisted, care being 
taken not to carry the torsion so far as to strangulate the tissues 
engaged in the constricting loop. Each suture is now clipped 
by a pair of scissors, about half an inch from the edge of the 
fistula, and by means of forceps pressed flat against the vaginal 
wall so as not to wound the opposite surface. 

The bladder should then be syringed out to remove all blood 
which may have accumulated there ; for if a large clot should be 
retained in this viscus it may cause severe vesical tenesmus, and 
smaller ones may block up the mouth of the catheter, which is 
to be kept in place permanently, and call for its repeated removal. 

Fig. 50. 
3 4 







Sutures twisted. (Wieland and Dubrisay.) 

The patient is now placed in bed by the assistants, an opiate is 
administered, and a Sims's sigmoid catheter is passed into the 
bladder and left there. The mouth of this instrument projects 
beyond the vulva, so that under it a small china dish may be 
placed, which will receive the urine as it passes through. 

The catheter should be examined every two or three hours to 



172 FISTULA OF THE FEMALE GENITAL ORGANS. 

be certain of its perviousness, and to remove the urine which 
collects in the receptacle placed under it. 

Once in every twenty -four hours the vagina should be syringed 
out with tepid water, or with this and white castile soap, or any 

Fig. 51. 




Sims's sigmoid catheter. 

similar detergent; but the bladder requires no further washing 
than that mentioned, except in cases of vesical tenesmus. The 
bowels should be kept constipated by opium. The diet should 
be governed by the same rules which guide us in the manage- 
ment of patients under other surgical operations. It should be 
nutritious and unstimulating. 

From the eighth to the fourteenth day the sutures should be 
removed. Dr. Sims declares that "it is unnecessary to allow the 
wires to remain longer than the eighth day ;" but others, calcu- 
lating upon the innocuousness of metallic substances in the tissues, 
have left them longer. In two of Dr. Schuppert's cases a leaking 
was detected when the bladder was injected on the sixth and 
seventh days, which had disappeared entirely on the twelfth, when 
the sutures were removed and the cure was found complete. 

To accomplish the removal of the sutures, the twisted end of 
one of them should be seized by a pair of forceps and drawn 
upon gently until the edge of the loop emerges from the tissues 
in which it has been imbedded. Then the blade of a pair of 
scissors should be inserted into the loop and one side cut, after 
which a little traction will remove the suture. 

An examination may then, with great caution, be instituted to 
ascertain whether success or failure has attended the operation. 
A visual examination will generally determine this. Should 
there be any doubt, the bladder may be filled very cautiously 
with tepid water to settle the question as to the entire closure of 
the fistula. Sometimes one operation fails to cure, although it 
diminishes the size of the fistula very much, and subsequent 
operations must be resorted to. It may be necessary to repeat 
these very frequently before success is attained. 



TREATMENT. 



173 



Fig. 52. 



"V 




Removal of the sutures. (Sims.) 



The operation of Dr. Sims has been variously altered in all its 
steps, so that now the number of modifications is quite numer- 
ous — so numerous, indeed, that it would be out of the province of 
a work like this to mention them in detail. In his earlier ope- 
rations Dr. Sims employed the quilled suture, which he called the 
clamp suture, but a tendency on the part of the little metallic 
bars, which he used in place of quills to produce ulceration, in- 
duced him to resort to the interrupted suture. 



17-i FISTULA OF THE FEMALE GENITAL ORGANS. 

Four years after the publication of Sims's method Dr. Nathan 
Bozeman, 1 of Alabama, now of this city, proposed a method which 
he regarded as an improvement upon it, and which he styled the 
"button suture." It may not be out of place to state here that, 
judging from the written testimony bearing upon this subject, 
Dr. Bozeman acknowledged the priority of the claims of Dr. Sims, 
and accorded him the credit of developing the principle upon 
which the cure in these cases is effected. But finding the clamp, 
which had up to that time been employed by Dr. Sims, open to 
a number of objections, he proposed a modification which he sup- 
posed would obviate them. In announcing his method, he says : — 

"I do not wish to be understood as attempting to detract from 
the great credit due from the profession and the public to Dr. 
Sims for his untiring perseverance in bringing his metnod to its 
present high state of perfection. I consider that this gentleman 
is fully entitled to more than all the praise that has been bestowed 
upon him both in America and Europe. To the honor of his 
professional brethren in this country it may be stated that no 
one has been found who has not gladly accorded to him the high 
distinction that he at present occupies." 

Bozeman's Operation. — " The edges of the fistule having been 
pared, the wire sutures are to be lodged in their respective places 
in the usual way, by attaching them to the ends of silk ligatures 
previously carried by means of a needle through the septum from 
one side of the fistule to the other. But in connection with this 
step of the operation, there is some difference between Dr. Sims's 
procedure and my own. In the first place I do not usually take 
so firm a hold of the tissues, the space between the entrance of 
the needle and the edge of the fistule rarely if ever exceeding 
half an inch, and it matters not whether the parts be indurated or 
not, the wire is not likely to cut out very soon. Secondly, it is 
not necessary to observe the same scrupulous care in entering 
and bringing out the sutures upon an exact line with each other; 
for, as will be hereafter understood, each one is in its action en- 
tirely independent of the others. Thirdly, instead of being 
obliged always to place the sutures parallel with each other, I 

1 Louisville Review, January, 1856. 



TREATMENT. 



175 



Fig. 53. 



have it in my power, if the peculiar nature of the case indicate, 
to insert them in any direction, and am thus enabled to bring 
within the sphere of successful treatment a large class of cases, 
which, owing to the irregular shape of the fistule, and the scarcity 
of tissue not admitting of extensive paring, cannot be subjected 
to the clamp suture." 

" The next step in the operation is to draw the raw edges closely 
in contact by bringing the opposite ends of each wire together. 
This may be readily accomplished with an instrument which I 
have invented for the purpose, and call the suture 
adjuster. It consists simply of a steel rod, fixed in 
an ordinary handle, its distal extremity flattened, 
perforated, and raised upon one side into a kind 
of knob, as represented by Fig. 53. The opposite 
ends of each suture are to be passed through the 
aperture in the end of the adjuster from the con- 
vex toward the flat surface, and while the former 
are held firmly between the forefinger and thumb 
of the left hand, the latter is carefully slipped down 
upon the wires until it comes closely in contact 
with the tissues. In this way the edges of the fis- 
tule are gently forced together, and, for the time 
being, the stiffness of the wire prevents their sepa- 
ration. Should it be found, however, that accurate 
coaptation does not take place, owing to the im- 
perfect manner in which the edges have been pared, 
the sutures may be readily loosened, and the defect 
remedied without the necessity of withdrawing the 
wires. The appearance of the parts after all the 
sutures have been adjusted is faithfully represented 
in Fig. 54. 

"A button of suitable shape and size having 
been previously provided, is now to be placed upon 
the wires (Fig. 55), its concave surface correspond- 
ing to the vesico-vaginal septum, and carried down 
in contact with the septum. The wires being again 
held in the left hand, the button should be pressed 
gently against and adapted to the surface of the parts (Fig. 55), 
This may be accomplished by an instrument which I call the 



Bozeman's su- 
ture adjuster. 



176 FISTULA OF THE FEMALE GENITAL ORGANS, 



button adjuster, consisting of a stiff iron rod, bent at a right 
angle within half an inch of its distal extremity, and inserted into 
an ordinary wooden handle. 



Fig. 54. 



Fig. 55. 






Sutures adjusted. Button being passed. 

"The shot are to be now passed down over the approximated 
ends of each suture to the convex surface of the button, and here 

each one is to be successively 
Fig- 56. grasped with a pair of strong for- 

ceps, and held against the button, 
while contraction is made upon 
the corresponding suture, in order 
to bring the vaginal surface of the 
septum in close contact with the 
Passing the shot. concave surface of the button, and 

insure close coaptation of the edges 
of the fistule. This having been accomplished, sufficient force is 
exerted upon the forceps to compress the shot and thus prevent 
its slipping. The operation is then concluded by clipping off the 
wires close to the shot." 

The advantages claimed by the inventor for this method are 
the following : — 

1st. It exerts a controlling influence in bringing the edges into 
apposition, and preventing inversion and eversion. 

2d. It gives steadiness and support to the edges of the fistula. 
3d. It protects the lips of the wound from contact with the 
secretions. 

Dr. Bozeman operates with the patients in the knee-elbow 
position, and not on the side. 

This operation, like that of Dr. Sims, has been variously altered. 



MASTIN'S OPERATION". 177 

Shields or splints of other forms have been substituted by Simp- 
son, Baker Brown, Agnew, Battey, and others; but as no new 
principle nor special advantage is developed by them, further 
mention would be superfluous. 

Dr. Startin and M. Matthieu, of Paris, have invented hollow 
needles, through which the silver threads can be passed without 
first passing those of silk. Needles, straight and curved, with 
long handles, are likewise employed by some. 

A very ingenious and simple needle, made by Messrs. Tiemann 
& Co., is represented by Fig. 57. By a sliding nut in the handle 
the metal suture is easily pushed through the hollow needle so as 
to facilitate its passage very materially. 

Fig. 57. 



£.Il£HAtl\-CO. 



Stohlmann's hollow needle. 

It will be remembered that the historical sketch given of this 
operation records the repeated use of pins, with figure of 8 sutures 
surrounding them, for closing fistula, and that as late as 1848 
Metzler, of Prague, employed them with good results. They 
are, however, not generally resorted to, and for that reason I, 
with the greater pleasure, describe the ingenious procedure of Dr. 
Mastin, of Mobile. 

Mastin 1 s Operation. — The lips of the fistula being pared in the 
ordinary manner, Carlsbad suture pins are held in a needle-holder 
and passed through both lips. Then a long silver wire is passed 
as a noose over both ends, and twisted by a Startin's or Coghill's 
twister, the points of the pins are cut off and a sponge placed in the 
vagina to support the sutured part. This is daily removed and the 
vagina syringed out. In removing the pins the head of each is 
seized by a pair of forceps, the pin is withdrawn, and the wire drops 
into the vagina. One great advantage claimed for the process by 
Dr. Mastin is this : if a leak is discovered, no new operation is 
necessary ; a tenotome is inserted, by twisting which the lips at the 
point of imperfect union are vivified, and an additional pin is 
passed through so as to bring them into apposition. The plan 
12 



FISTUL.E OF THE FEMALE GENITAL ORGANS. 



certainly recommends itself for simplicity, and since it has uni- 
formly succeeded in the hands of its inventor deserves trial. Figs. 
58 and 59 show the steps of the operation very clearly. 

Fig. 58. 

i * * 







Mastin's operation : a a a, wire threads surrounding b b b, pins in position. 

Fig. 60. 





"Wound closed : c c c, threads twisted 
so as to close the fistula ; and d d d, 
pins cut short. 



Coghill's twister employed in the operation. 



CLOSURE OF THE VAGINA. 



179 



ElytropJasty. — This operation was published to the profession 
by Jobert de Lamballe, 1 in 1834, and was subsequently altered 
and improved by Velpeau, Gerdy, and Leroy d'Etiolles. It con- 
sists in dissecting a flap from one buttock (Jobert), or the posterior 
wall of the vagina (Yelpeau and Leroy),^and fixing it by sutures 
into the orifice of the fistula, the borders of which have been pre- 
viously pared. It resembles the operations of rhinoplasty per- 
formed upon the face, but is unfortunately even more difficult 
than they, and calls for such great manual dexterity as to preclude 
its frequent adoption. Yelpeau, by making two parallel, longi- 
tudinal incisions in the vagina, dissected up the intervening tis- 
sue and stitched it to the edges of the fistula. 

Leroy prolonged these incisions to the vulva, dissected up the 
intervening flap, and, rolling this upon itself, applied its under or 
bleeding surface against the fistula. 

Elytroplasty is still resorted to sometimes where great destruc- 
tion of tissue has taken place at the base of the bladder, but the 

Fig. 61. 




Example of a case requiring obliteration of vagina; a and c were united. (Sims). 

difficulties and uncertainties attending it, together with the fact 
that more simple and efficient methods for dealing with this class 
of cases are at command, have rendered a resort to it very rare. 

Closure of the Vagina. 

This procedure is resorted to in despair of accomplishing the 
cure of the fistula, and in the hope of relieving- the patient from 

1 Bull, de l'Acad. de Med. de Paris, t. ii. p. 146. 



180 FISTULA OF THE FEMALE GENITAL OEGANS. 

the intolerable annoyance attendant npon an involuntary and con- 
stant discharge of urine. It is proposed only for those cases in 
which, from extensive destruction of tissue, no hope of closure by 
suture or elytroplasty can be entertained. By it the vagina and 
bladder are rendered a common receptacle for urine and men- 
strual blood, the only advantage gained consisting in the fact that 
they may be retained and discharged at volition through the ure- 
thra which remains open. Closure of the vagina may be accom- 
plished by two operations, episiorrhaphy and obliteration of the 
canal. Neither of these, however, can be regarded as reliable or 
efficient methods, since they involve the necessity of the urine 



Fig. 62. 




Obliteration of the vagina. (Wieland and Dabrisay.) 

being retained in the vaginal canal, which is injured by its pre- 
sence. 



URINARY FISTULA. 



181 



The first consists in paring the inner surfaces of the labia majora 
and uniting them by suture so as to cause their complete adhe- 
sion, The operation is exceedingly simple in its steps, but 
a very minute opening almost invariably remains just under the 
meatus through which a little urine exudes. This very nearly 
invalidates the success of the method, for even a slight escape 
renders the patient uncomfortable. 

The second consists in paring, not the labia, but the lower 
extremity of the vaginal walls. Strips of mucous membrane 
being thus taken away, the bleeding surfaces are brought in con- 
tact by suture, and the bladder kept empty by a catheter until 
union has occurred. Dr. Bozeman, of this city, was the first to 
perform a modification of this method, which Simon, of Eostock, 
subsequently adopting styled "cross obliteration." It consists in 
bringing the remains of the vesico-vaginal wall, which has been 
nearly destroyed by sloughing, into union with the posterior 
vaginal wall, so that the vaginal orifice is closed transversely. 



Urinary Fistula requiring Special Treatment. 

In the great majority of instances no other plan of treatment than 
the suture is ever thought of. There are, however, some cases 
of urinary fistulse in which the application of the suture is diffi- 
cult, or even impossible. These will now engage our attention. 

Vesico-uterine Fistulse. 

Jobert first pointed out the proper method 
for reaching these. His plan is not at pre- 
sent employed, but that now regarded as 
most reliable is only a modification of it. It 
consists in slitting up the anterior lip of the 
uterus until the fistula is reached, vivifying 
its edges and passing sutures directly through 
the cervix, as represented in Fig. 63, so as to 
approximate the walls of the cervix and the 
lips of the fistula. 

In case the fistulous orifice be so high as 

, . , , , ^ ■. ,i t The cervix is slit to ex- 

to be considered beyond reach, the only re- poge the fotula aboV6j 
maining resource is to close the os uteri ex- ami sutures are passed. 




182 FISTULJ3 OF THE FEMALE GENITAL ORGANS, 



ternum by suture, and allow menstruation to occur through the 
bladder. 

Vesico-utero-vaginal Fistulse. 

For these the plans of Jobert and Bozeman of vivifying the 
anterior lip of the os, and thus making the uterine tissue subser- 
vient to closure of the fistula, are peculiarly applicable. The ope- 

Fig. 64. 




Anterior lip of fistula united to anterior lip of cervix. 



Fie. 65. 




Anterior lip of fistula united to posterior lip 
of cervix. (Wieland and Dubrisay.) 



ration, represented at Fig. 64, is 
similar to that for ordinary vesi- 
covaginal fistula, the only dif- 
ference being that one lip of 
the fistula is made of the vivi- 
fied cervix uteri. 

In case the anterior lip of the 
uterine neck be so completely 
destroyed that it cannot furnish 
the requisite tissue for this pur- 
pose, the vagina may be united 
to the posterior lip so as to 
throw the cervix into the blad- 
der. Menstruation will there- 
after occur into that viscus, and 
the blood thus accumulating be 
discharged with the urine. 



URINARY FISTULA, 183 

Fistulas with Extensive Destruction of the Base of the Bladder. 

It has already been mentioned that elytroplasty and occlusion 
of the vagina offer resources in these cases, but neither of these 
operations is likely to produce good results as a general rule. 
To Dr. Bozeman we are indebted for a much more reliable pro- 
cedure, which consists in daily dragging the uterus down for 
weeks before the operation by means of a pair of forceps by 
which the neck is seized. By this means the uterus is made to 
approximate the vulva. Then one lip of the cervix, being vivified, 
is brought into contact with the extremity of the remains of the 
vesico- vaginal septum and firmly united with it by suture. 

In addition to the varieties of urinary fistulas mentioned here, 
certain rare instances of union between the ureters and vagina or 
uterus have been recorded. A case of what the author styles 
uretero-uterine fistula may be found in the Dictionnaire de Medecine 1 
vol. XXX., from the pen of M. Berard. It is not only interesting 
in itself, but as displaying the logical process of reasoning by 
which the diagnosis was made is worthy of special mention. Ke- 
garding it at first as a vesico-uterine fistula, from the fact that 
urine was discharged from the uterus, he arrived at a different 
diagnosis, from these facts : — 

1st. The urine flowed steadily from the cervix when the blad- 
der was empty. 

2d. The urine thus flowing was limpid, unlike that from the 
bladder. 

3d. The patient being kept seated over a vessel for two hours, 
so as to preserve all the urine flowing per vaginam, a catheter 
was passed into the bladder and exactly the amount was removed 
which had escaped vicariously. 

4th. Injecting the bladder with fluid colored by indigo, the 
urine passing per vaginam remained limpid. 

5th. A sound being passed into the uterus and another into the 
bladder, their points could not be brought into contact. 



CHAPTEE XI. 



FECAL FISTULA. 



Definition. — These fistulae, wlrich are much less frequently met 
with than the urinary, consist in communications established 
between the vagina or vulva and some part of the intestinal 
tract. 

Varieties. — They may be recto-vaginal, entero-vaginal, or recto- 
labial ; the first being the most common, and the second the 
rarest of the varieties. 

Causes. — The causes which produce them are almost identical 
with those which result in urinary fistulas, viz : — 
Prolonged pressure ; 
Direct injury; 
Ulceration or abscess. 

The first of these may produce them, as it does those occurring 
on the anterior vaginal wall, by creating an intense inflammation 
which results in sloughing, or the intensity of the pressure may 
be so great as rapidly to destroy the vitality of the part. Such 
pressure is most frequently the result of difficult parturition, 
but in rare cases it may arise from badly-fitting pessaries or 
scybalous masses in the rectum. 

Direct injury by instruments used in delivery, or others em- 
ployed for removal of impacted feces, may evidently produce 
them. 

Ulceration or Abscess. — These pathological conditions much 
more frequently produce this than the urinary form of fistula. 
For the recto-vaginal variety stricture of the rectum is a fruitful 
source, the stricture producing a retention of fecal matters which 
excites ulceration that may extend to the vaginal canal. An 
abscess between the vagina and rectum may cause a communica- 
tion between the two, or burrowing towards one labium may open 
there and connect this part by a tract with the rectum. In the 



PHYSICAL SIGN'S. 185 

same manner a purulent collection has been known to make a 
junction between the caput coli and vagina. Lastly, syphilitic 
and cancerous ulceration may open a channel between the intes- 
tinal and vaginal canals. 

Symptoms. — The most prominent, often the only symptom 
which will attract the patient's attention, will be a discharge of 
offensive gas or fecal matter by the vagina. The amount which 
escapes will of course be governed by the size of the fistula, but 
the annoyance dependent upon the accident will not be so, for 
even the smallest quantity will be sufficient to render the patient 
utterly wretched by the offensive odor to which it gives rise. 

Physical Signs. — The patient being placed upon the back, the 
touch should be practised upon all the surface of the vagina. If 
the fistula be one of any magnitude, this will at once discover it. 
If not, careful exploration by the speculum will almost always do 
so. Sims's speculum should be introduced under the symphysis 
so as to lift the anterior wall of the vagina while the lateral walls 
are held aside by spatulas. Should visual exploration not reveal 

Fig. 66. 




Examination for fecal fistula). (Wieland and Dubrisay.) 

the opening, the rectum may be filled with tepid water colored 
with cochineal or indigo, and its escape carefully watched for. 



186 FECAL FISTULA. 

Prognosis. — Fecal fistulas are more likely to be spontaneously 
recovered from than those of urinary character, from the fact that 
they give passage to gaseous and semifluid excretions, and not to 
an irritating fluid which is constantly dribbling away and keeping 
the fistulous walls from uniting. But even these are rarely re- 
covered from unless surgical aid be brought to their relief. 

Treatment. — Eecto-vaginal and recto-labial fistulas may be 
treated by the following methods : — 

Cauterization ; 

Suture ; 

Incision ; 

Ligature. 
Cauterization may be effected by one of the strong mineral 
acids, nitrate of silver or the actual cautery. If the fistula be 
direct, any one of these may be employed. If it be indirect, a 
probe, the point of which has been covered by a coating of nitrate 
of silver by dipping it when that substance is in a state of fusion, 
will be the most appropriate plan. After cauterization the rectum 
should be kept perfectly quiet by opiates, and a glass plug should 
be worn in the vagina. In cases of recto-labial fistulas, Prof. Simp- 
son speaks in high terms of the injection of strong tincture of 
iodine through the fistulous tract. 

Suture. — This is practised upon the same plan as that which is 
followed in vesico-vaginal fistulas, with these exceptions, that the 
patient is placed in the position adopted in operating for stone, 
and that the speculum is so inserted as to elevate the anterior 
instead of the posterior vaginal wall. After the operation, the 
rectum, which, should have been thoroughly emptied by enema 
before it, should be kept perfectly quiet by opiates for ten or 
twelve days. When evacuations are first permitted laxatives 
should be employed in order to avoid tenesmus, which might de- 
stroy the union of the lips of the fistula. The cure by suture is 
not applicable to cases of recto-labial fistula, but only to recto- 
vaginal. 

Incision. — Should the opening be near the sphincter ani, the 
recto-vaginal wall together with the sphincter may be incised so 
as to unite the two canals from the fistula downwards. A pledget 
of lint is then placed in the wound, which will heal from its deep- 
est portion. Prof. I. E. Taylor, of this city, has recently reported 



SIMPLE VAGINAL FISTULA. 187 

40 cases, of which 36 or 37 were cured by a method for which he 
credits Dr. Ehea Barton, of Philadelphia, and which he thus 
describes: "The treatment consists in full and complete division 
of the whole sphincter ani, laterally, either by the use of the specu- 
lum ani, or simply by the finger introduced, and dividing the 
sphincter from within outwards, which I much prefer. The sphinc- 
ter ani is divided on the side (the left being the most frequent), 
where the external orifice is found. If the fistula is double, then 
divide the sphincter ani on both sides laterally. In all the cases 
operated upon the sphincter ani has closed up well and remained 
perfectly natural. The fistula externally, either in the vagina 
or on the labia, is not touched, either by caustics or suture. The rule 
which guides the surgeon at the present day, as proposed by 
Brodie, Syme, Curling, and Quain, where the internal opening in 
fistula in ano is high up, is not to disturb or touch it, but let it 
alone. Experience has taught that the internal opening in the 
case of fistula in ano, though two to three inches high up, will 
close, after the sphincter ani only is divided through to the ex- 
ternal orifice, and so it is with recto-vaginal and labial fistulas of 
the nature I refer to." 

Ligature. — This method consists in the passage of a silk thread, 
by means of a bent probe, through the fistula, so as to embrace 
the recto- vaginal septum between the fistula and the perineum. 
A silver ligature being then attached to one of its ends, is drawn 
into place by it and tightened every day until it cuts its way out. 

ENTERO-VAGINA.L FISTULA. 

Entero-vaginal Fistula, which consists in a fistulous tract be- 
tween part of the intestinal canal above the rectum, and the vagina, 
is rare, and when existing should be looked upon as an artificial 
anus, the closure of which would be attended by danger. If the 
opening is direct and there be no tract leading from one canal to 
the other, this would not be the case, but if a tract exists, the 
closure of its vaginal extremity would probably result in abscess 
excited by fecal matters passing out of the intestine. 

SIMPLE VAGINAL FISTULA. 

Definition. — Under this head is grouped those forms of fistulous 
connection with the vagina which do not act as vicarious outlets 



188 FECAL FISTULA. 

for any neighboring organ, as, for example, peritoneo- vaginal, 
perineo-vaginal, and blind fistulse. 

Peritoneo- vaginal fistula has been rarely met with. When it 
does occur it is attended by danger of descent of the intestine into 
the vagina, and- entrance of fluids and air into the peritoneal 
canity. One reason for its rarity is probably the fact that no ex- 
crementitions substance passing through it, it very generally dis- 
appears without becoming chronic. Should it not do so, no 
annoyance would arise from its existence, and it would be sus- 
ceptible of immediate cure by suture. 

Perineo-vaginal fistula may result from partial closure of a rup 
tured perineum leaving a small orifice near the sphincter ani, or 
from penetration of the presenting part of the foetus through the 
perineum. It would be readily cured by incision, ligature, 
cauterization, or injection, after the plan just pointed out in con- 
nection with fecal fistulas. 

Blind vaginal fistulas are those which lead to a purulent collec- 
tion in some part of the pelvis. They will be fully treated of 
when considering pelvic abscesses, and nothing need be said of 
them here further than to recapitulate the principles upon which 
their treatment rests : 1st, dilatation of the fistulous tract by tents 
or incision ; 2d, exerting an alterative action on the walls of the 
abscess by iodine, iron, nitrate of silver, water, &c. &o. 



CHAPTEE XII. 

GENERAL REMARKS UPON INFLAMMATION OF THE UTERUS. 

Importance. — He who desires to become conversant with the 
diseases peculiar to woman, to fully comprehend their pathology, 
and to be successful in their treatment, will do well to make the 
thorough understanding of inflammation of the non-pregnant 
uterus the basis of his education in this department of medicine. 
It is true that many diseased states of the pelvic viscera of the 
female are due to other causes, but it is not less true that the majo- 
rity either take their rise in this, or in their progress become com- 
plicated by it, so that it forces itself constantly upon the notice 
of the Gynecologist as the keystone of the arch upon which rest 
his knowledge and usefulness. These facts were, to a certain 
extent, recognized by the physicians of the Grecian and Roman 
schools, but judging from those of their works which have 
reached us, their appreciation of them did not compare in 
thoroughness with that of our century. After the revival of let- 
ters the importance of the pathological view, which gave to me- 
tritis such prominence and moment, was almost entirely lost sight 
of until the beginning of the nineteenth century, when Recamier 
and Lisfranc reinstated it. It has been already stated that to Dr. 
J. H. Bennet we owe its dissemination not only in his own country 
but throughout America. 

Parts Affected. — The parts of the uterus which may be affected 
by inflammation are, first, the mucous lining, and second, the 
parenchyma. The morbid action may limit itself to either one 
of these, though it rarely does so strictly, one usually, to a greater 
or less extent, complicating the other. But not only may the 
disease limit itself to one or other of these tissues ; it very gene- 
rally confines itself to one portion of the affected organ, the neck 
or the body being the part forming its habitat. 



190 BE 31 ARKS UPON INFLAMMATION OF THE UTERUS. 

A transverse section of the uterus passing through the os in- 
ternum divides the organ into two distinct parts, which are dis- 
similar not only in anatomical but in physiological and patholo- 
gical peculiarities. This makes a separate consideration of the 
diseases of the two parts, and an appropriate nomenclature neces- 
sary both for convenience and for facility of comprehension. If 
the mucous lining of the organ be diseased, the term endometritis 
has been applied to the condition, and if the parenchyma be the 
site of the morbid process, that of parenchymatous metritis, or 
simply metritis, designates it. But each of these forms must be 
divided into two others, according to the portion of the uterus 
affected, and the varieties of metritis may be clearly expressed 
in the following manner : — ■ 

Varieties of uterine inflammation. 
Endometritis — 
Cervical ; 
Corporeal. 
Metritis — 
Cervical ; 
Corporeal. 

Some important facts connected with these varieties of metritis 
may be thus stated in propositions : — 

1st. The cervix is much more frequently affected by inflamma- 
tion than the body of the uterus. This was first insisted upon 
by Dr. Bennet, and its substantiation constitutes the marked feature 
of his work on the uterus. 

2d. Metritis, whether cervical or corporeal, is generally the 
result of parturition or abortion. 

3d. Cervical metritis, which is very common in matrons and 
multiparas, is rare in nulliparae, and extremely rare in virgins. 

4th. The form of uterine inflammation most commonly met 
with in virgins and nulliparae is corporeal endometritis. This 
view, of the truth of which I have long felt satisfied, I regarded 
as original until I met with it clearly and fully stated in the 
works of Nonat and Aran. 

5th. In their acute forms both the mucous and parenchymatous 
varieties are apt to invade the whole of the structure first affected, 
but in their chronic forms this is not so. The body or the neck 
may be alone affected for years ; in the one case the morbid pro- 



PROGNOSIS IK UTERINE AFFECTIONS. 191 

cess not coming down below the os internum, and in the other not 
ascending above it. 

Prognosis in Uterine Affections. — There is no organ of the body 
the inflammatory diseases of which offer greater difficulties in 
prognosis than those of the uterus. So much depends upon the 
habits of the patient, the injurious influences to which she is ex- 
posed, and the faithfulness with which she follows out the direc- 
tions of the physician, that often very little can be predicted, very 
little promised with any certainty. The error into which the in- 
cautious practitioner is most likely to fall is that of predicting 
a cure at too early a period, and fixing some definite time for 
its accomplishment. The patient may declare that she and 
her friends will be satisfied even if the limit be fixed not by 
months but by years, nevertheless she is desirous of knowing 
when she may confidently expect a cure. The answer to this 
question, not in the lesser interest of the practitioner, but in the 
greater one of the patient, must often be that no such time can 
possibly be determined upon. In some cases it becomes necessary 
to state further that not only is the time but the certainty of com- 
plete cure doubtful ; that local treatment will result in pain, may 
result in danger, and may absolutely aggravate the existing 
symptoms. 

Another point which influences prognosis is this : in the 
management of uterine diseases it is of primary importance that 
the practitioner should enlist the interest and co-operation of bis 
patient. Should she be apathetic with regard to the result, or 
even having begun treatment with enthusiasm, become disaffected 
from any cause, his duties will probably prove irksome, annoy- 
ing, and fruitless. For this reason he should be cautious in urg- 
ing with too great earnestness the adoption of local treatment. 

In view of this and the additional fact that treatment may ex- 
tend over months, and perhaps occupy years, before a cure is 
effected, the physician should avoid all resources which by 
their uncleanliness or disagreeableness may disgust a refined 
patient, or make her rather willing to bear her disease than the 
means adopted for its cure. If such means will be very likely 
to give relief, they should of course be employed ; but if, as is 
the case with many of them, their efficacy is extremely doubtful, 
they should not be insisted upon. For example, if a lively, fasti- 



192 REMARKS UPON INFLAMMATION OF THE UTERUS, 



dious lady were called upon, for the relief of an endometritis 
which is not in itself very annoying, to forego society and spend 
most of her time in bed ; to fill the vagina daily with a semi-solid 
mass of powdered linseed after the method of Melier ; to rub mer- 
curial ointment over the hypogastrium, and have a weekly appli- 
cation of leeches around the anus, she would probably in time 
get tired of the treatment, and lapse into the very state of apathy 
to which I have alluded. 

There is one class of cases in dealing with which I should espe- 
cially recommend that perfect frankness be observed. It may be 
represented by a patient who has been persuaded by husband, 
mother, or friends, contrary to her wishes, to submit to treatment. 
She utterly repels the course to be adopted, is sure that it will do 
her no good, is unwilling to fulfil the directions left her for daily 
guidance, but yields, under the assurance of her advisers that the 
treatment will be free from discomfort, give no pain, and will 
surely cure her in a few weeks. The physician, for the sake both 
of his patient and himself, should avoid joining in this deception. 
Stating the facts fully to her, telling her of the danger which 
neglect will involve, and of her duty un- 
der the circumstances, he should appeal 
to her reason, and decline to take charge 
of her case until she really desires his ser- 
vices. 

There is a general rule which I have 
kept before me as a guide to prognosis, 
and which has so rarely failed me that I 
urge it upon the attention of the reader. 
If the disease affect that part of the uterus 
below a line running across it at the junc- 
tion of the neck and the body, it matters 
not how grave the affection, either of mu- 
cous or parenchymatous tissue, if it be not 
of malignant type, a prospect of cure may 
be held out. Should the morbid action 
exist above this line, even if it present no 
features of special gravity, the physician 
should be cautious in his promises of cure, and fix no limit as to 
time. It is true that recent cases, and sometimes even old ones, 



Fig. 67. 




A represents the dividing line 
between body and cervix. 



PROGNOSIS. 193 

of corporeal endometritis and metritis may be cured ; but in those 
which are recent, cure is always very difficult, and in those which 
are chronic often impossible. 

Reasons for the frequency of Failure in the Treatment of Uterine 
Diseases. — That some uterine affections of non-malignant type are 
incurable cannot be denied ; • but even putting these out of con- 
sideration, the fact is notorious that the local treatment of these 
diseases is not as flattering in its results as we could wish. I now 
propose an investigation into the causes of this want of success. 
It appears to me that the most apparent and most constant of 
them may thus be summed up : — 

Imperfect diagnosis ; 

Erroneous prognosis ; 

Inefficient therapeutics ; 

Inattention to general management. 
Imperfect Diagnosis. — It is not rare to meet with instances in 
which physicians have, for months, treated cases of uterine dis- 
ease concerning the nature of which they not only did not have 
a correct theory, but had no theory at all. Under these circum- 
stances the most general practice is to pass, about once a week, a 
solid stick of nitrate of silver up to the os internum, not to cure 
cervical endometritis, for that has never been suspected, but to do 
the best one can in the way of treatment, when he does not know 
the nature of the disease which he treats. I have no inclination 
to attribute this to any intentional laxity of morale, but rather to 
indecision and aversion to creating a disagreeable issue with the 
patient. It is, however, impossible to deny the fact that such a 
course will sometimes be pursued by those who in the case of a 
diseased eye, or inflamed knee-joint would not hesitate to confess, 
with the utmost frankness, their uncertainty and need of assistance. 
"With uterine as with all other diseases the diagnosis must be 
properly made before treatment can prove curative. 

Erroneous Prognosis. — Even if the diagnosis and treatment be 
correct, an erroneous prognosis as to time of cure may so sap the 
confidence of the patient as to send her to other counsel. And 
now she may run the gauntlet of theories and therapeutics. Her 
first attendant having recognized corporeal metritis with resulting 
displacement, the second may treat the displacement alone, as the 
origin of her symptoms. Passing into the hands of a third, she 
13 



194 REMARKS UPON INFLAMMATION" OF THE UTERUS. 

may be told that to check her profuse leucorrhcea would be to 
cure her, which the fourth might contradict, with the assertion 
that the uterine disorder was only a complication of ovaritis, 
which was the fountain of all her difficulties. 

Inefficient Therapeutics may cause failure in cure even when a 
proper diagnosis and prognosis have been made. Sometimes a 
too gentle course of local alteratives may be persevered in when 
disease of the parenchyma demands more vigorous caustics. At 
others it is necessary to carry the caustics up into the cavity of 
the body, and not of the neck alone ; and at others still, to per- 
form a trifling surgical operation to remove a difficulty which 
without it may keep up the disease indefinitely. 

Inattention to General Management and Hygiene. — -The.statement 
which we often meet with, that the majority of the cases of uterine 
disease require no local treatment whatever, is a fallacy, based 
upon strong prejudice against one of the most important modern 
improvements in medicine, or upon want of experience in such 
cases. But too much stress cannot be laid upon the advantages 
to be derived from constitutional treatment and the general man- 
agement of these cases. We too often fail to insist upon rest, ces- 
sation of marital intercourse, quietude after applications to the 
uterus, and other points, a neglect of which may exert a powerful 
influence for evil, and frustrate the effects of all that is done by 
local means. 

Astruc begins his directions for treating uterine ulcers by ad- 
vising — 

" 1. To charge the patient to abstain from all kinds of exercise 
and to keep constantly laid down on a long seat." 

" 3. It is for the same reason fit, in the case of a married woman, 
that she should lie separately from her husband." 

"5. They should for the same reason guard against all the 
passions of the mind that may agitate it, as grief, uneasiness, and 
anger, &c." 

This advice, given over a century ago, is often neglected to-day, 
and too much reliance placed upon local means, and upon them 
alone. Everyone who has had experience in the treatment of 
these disorders must have been struck with surprise at the wonder- 
ful improvement exerted upon cases, which have long resisted 
local means, by a sea- voyage, a visit to a watering-place, a course 



GENERAL MANAGEMENT AND HYGIENE. 195 

of sea-bathing, or a few months passed in the country. Not only 
is this improvement manifest in the general state of the patient ; 
it shows itself locally, also, and in some cases even recovery may 
be thus attained. The same fact is equally noticeable in old ul- 
cers of the leg; local means, the efficacy of which, in such 
cases, no one doubts, having failed in producing good results, 
entire recovery is effected by means, such as those alluded to, 
which act upon the constitution. 



CHAPTEE XIII. 

ACUTE ENDOMETEITIS. 

Synonymes. — Acute uterine leucorrhoea, acute uterine catarrh, 
acute internal metritis. 

Frequency. — Acute inflammation of the lining membrane of the 
uterus is a condition which occurs quite frequently. Often run- 
ning a rapid course, however, and ending in recovery or chronic 
disease, it passes unrecognized in many cases. In this way I 
would explain many of the cases of suppressio mensium and con- 
gestive dysmenorrhea, which we so often find ending in chronic 
disease. And thus also do I account for the profuse and painful 
attacks of leucorrhoea occurring with exanthematous fevers, and 
lasting for a length of time after they have passed off. It is very 
generally stated that acute metritis is seldom met with except as 
a sequel of parturition, and I agree in the statement as applying 
to parenchymatous inflammation, but it is incorrect as regards 
endometritis, which often proves the source of sudden menstrual 
disorder and the cause of violent leucorrhoea. 

Varieties. — The morbid process may affect the lining membrane 
of the cervix or body alone, or it may attack the whole uterine 
mucous tract, its selection of site being governed by its cause. 
Thus, that form which immediately follows parturition or abor- 
tion or results from gonorrhoea, is likely either to affect the whole 
mucous tract or the cervical canal alone ; while that which is due 
to sudden checking of the menstrual flow is generally confined to 
the body. 

Causes. — The causes of acute endometritis are as follows : — 

Direct injuries ; 

Acute vaginitis ; 

Certain constitutional diseases; 

Interference with the menstrual flow ; 

Parturition ; 

Evacuation of retained menstrual blood. 



SYMPTOMS. 197 

Examples of direct injuries which may produce acute endo- 
metritis are the introduction of the uterine sound or the intra- 
uterine pessary, the employment of tents or the application of 
chemical irritants. 

Specific vaginitis or gonorrhoea will sometimes pass up into 
the cervix and body of the uterus, and out through the Fallopian 
tubes, creating pelvic peritonitis of most violent character. Even 
simple vaginitis, when of very severe form, may do so, though 
this is by no means common. 

The peculiar blood state, attending upon and forming an ele- 
ment of measles, scarlatina, variola, and roseola, and its influence 
on all the mucous linings of the body, will sometimes result in 
general endometritis, and the hsemic condition resulting from 
phthisis not rarely does so. 

Exposure to cold and moisture, great mental anxiety, or any 
other influence which suddenly checks the menstrual flow, very 
frequently produces this disease. At the moment of exposure 
what is termed suppressio mensium, or congestive dysmenorrhoea, 
may take place, and from that time endometritis exists. When 
we consider that such a sudden check of menstruation will some- 
times result in hematocele of fatal character, it is certainly not to 
be wondered at that it may likewise produce the disease of which 
we are speaking. 

Parturition of normal type is a well-known cause of general 
endometritis. In some cases it may, however, produce cervical 
disease alone, the body being unaffected. It is much more fre- 
quent after unnatural deliveries, or where the parturient act has 
been frequently and rapidly repeated, or has occurred in one who 
previously suffered from chronic endometritis. 

It is a well-known fact that when menstrual blood is retained 
for a long time in utero by an obstruction in the vagina or at its 
mouth, by an imperforate hymen, for example, the severance of 
the occluding medium and admission of air will often result in 
endometritis of dangerous and even fatal character. Such cases 
appear to resemble very closely the septic endometritis which 
occurs after parturition, and constitutes the first step towards 
puerperal fever. 

Symptoms. — The disease demonstrates its presence in the non- 
pregnant uterus without any very violent symptoms. 






198 ACUTE ENDOMETRITIS. 

Ordinarily the patient complains of pain, weight, and dragging 
in the pelvis ; pain in the back, groins, and thighs ; and vesical 
and rectal tenesmus. After three or four days there is usually a 
discharge of a viscid liquid which rapidly becomes creamy, puru- 
lent, and perhaps bloody, tympanitis and sensitiveness upon pres- 
sure, and uterine tenesmus or " bearing-down pains." 

Physical Signs. — An examination by touch reveals the vagina 
hot and dry or covered by the discharge noted above. The os uteri 
is found gaping, the cervix swollen and very sensitive to pres- 
sure, the body slightly enlarged, and the whole organ lower than 
normal in the pelvis. Through the speculum the cervix is found 
to look swollen, cedematous, and red, and from the pouting os 
pours forth either a clear, albuminous-looking fluid, muco-pus, 
or long tenacious shreds of cervical mucus. The probe, if used at 
all, should be employed with great caution. It will discover great 
sensitiveness throughout the uterine cavity, and the slightest 
touch upon the fundus will cause a few drops of blood to flow. 
Indeed, so great is the engorgement that the speculum will often 
cause blood to flow from the cervix. 

Differentiation. — The only diseases with which this would with 
any probability be confounded, are pelvic cellulitis, peritonitis, and 
acute vaginitis. Physical exploration would so easily settle the 
point that it requires no further consideration. 

Pathology. — In its first stage acute endometritis consists in an 
intense and active hyperemia of the mucous lining of the uterus, 
which is red, swollen, cedematous, and softened. Its surface is 
spotted, Scanzoni declares, from congestion of a capillary network 
around the mouths of the utricular follicles. When the second 
stage has set in, the cavity of the uterus is found to contain an 
excess of mucous or creamy-looking pus which may be more or 
less mingled with blood. In this inflammatory engorgement the 
mucous membrane of the vaginal portion of the cervix, if the 
cervix be involved, participates markedly, as an examination by 
the speculum will prove. 

Complications. — The complications of the disease are urethritis, 
cystitis, vaginitis, salpingitis, and sometimes pelvic peritonitis. 

Course, Duration, and Termination. — Acute endometritis, when 
occurring in the non-pregnant state, may, without treatment even, 
go on to recovery, generally lasting from a month to six weeks, 
and perhaps passing through its whole course without its exist- 



PROGNOSIS — TREATMENT. 199 

ence having been ascertained. It sometimes ends in the chronic 
form of mucous inflammation or even in metritis, the superficial 
layers of the subjacent parenchyma becoming affected. Indeed, I 
doubt very much if any case of severe endometritis runs its course 
without being to a greater or less extent complicated by a slight 
degree of metritis. As already stated the disease may end in 
chronic endometritis or in recovery. It may, likewise, end in 
death, inflammatory action spreading along the Fallopian tubes 
and causing salpingitis, which, by resulting in free purulent dis- 
charge into the peritoneum, may establish inflammation there. 

Prognosis. — In spite of all these possibilities the prognosis is 
always favorable if the patient takes ordinary care of herself and 
yields to a judicious plan of treatment. 

Treatment. — The diagnosis having been clearly made, treatment 
should be at once established. Complete rest of mind and body 
should be regarded as essential points, the woman being kept 
quiet in bed. Should there be severe pelvic pains, the patient be 
plethoric, or suppressio mensium be present, a few ounces of 
blood may be taken from the cervix or perineum by leeches, at 
intervals of three or four days, and twice or three times every day 
a stream of water, at a temperature of 100° Fahr., should be 
thrown, by means of a syringe with continuous jet, against the 
cervix. The bowels should be regulated by saline cathartics, 
unless diarrhoea exists, and all beverages likely to irritate the 
bladder be avoided, as, for example, alcoholic stimulants and 
strong coffee and tea. Warm fomentations should be applied to 
the hypogastrium, and, should pain exist, anodynes administered 
by the rectum or vagina. Of the two channels I prefer the former, 
though in some cases great relief may be obtained from a sup- 
pository of opium or belladonna applied directly against or within 
the cervix. After the severity of the attack has been subdued 
and examination by the speculum becomes to a certain extent pain- 
less, the vaginal portion of the cervix and the whole cervical canal 
should, if this be the part of the organ chiefly affected, be painted 
over with a solution of nitrate of silver, about one scruple to the 
ounce of water, and this may be repeated twice a week with ad- 
vantage. 

Under this plan of treatment the patient should be kept until 
recovery, or until we are admonished by time that the disease has 
passed into its chronic form and requires different remedies. 



CHAPTEB XIV. 

ACUTE METRITIS. 

Definition and Synonymes. — By this term is designated acute 
inflammation of the parenchyma of the womb, in contradistinction 
to that of its investing membrane. As already stated, neither 
disease ever occurs and runs its usual course without, to a limited 
extent, producing the other. In treating of them after the plan 
here adopted it is intended to convey the idea that, in certain cases, 
one or other structure is the main point of attack, and disease of 
the adjoining tissue only a complication. 

Frequency. — With reference to its frequency many conflicting 
statements will be found. This arises partly from the fact that 
some have written of the affection without making any distinction 
between the forms occurring in the pregnant and non-pregnant 
states, while others have confined their remarks, as is here done, 
to diseases of the latter condition; partly from endometritis, 
active congestion from suppressio mensium, and pelvic cellulitis 
having been mistaken for metritis ; and in great part from the 
difficulty of gaining post-mortem evidence, the disease generally 
being recovered from. My own experience leads me to regard it as 
of extremely rare occurrence, since I have met with it but twice in 
a practice which has afforded abundant opportunities of seeing 
uterine disease. One of these cases resulted from slitting one 
wall of the cervix uteri up to the vaginal junction, and the other 
from the use of a badly-fitting pessary. During this time I 
have seen numbers of cases which were regarded by others as 
of this character, and quite a number which I viewed as such 
until enlightened by post-mortem or other evidence. Eokitansky 
declares that, " in acute inflammation of this organ, generally the 
lining membrane of the uterus is affected primarily, and that this 
is scarcely ever the case with the uterine tissue, as far as can be 
demonstrated by the pathological anatomist, with the exception 



VARIETIES — CAUSES. 201 

of the reaction following traumatic influences, especially of the 
vaginal portion." 

Some practitioners are prone to regard every case of inflamma- 
tory action in the pelvis, accompanied by great tenderness over 
the uterus, as metritis. They are much more frequently due to 
pelvic cellulitis or peritonitis, which are by no means rare affec- 
tions, or to active congestion, caused by suppression of the 
menses or excessive coition. After parturition, either at term or 
premature, true metritis does occur not infrequently, but this 
variety does not concern our present investigation. As regards 
that form which we are considering I feel convinced that if the 
experienced practitioner will put aside his preconceived views 
and interrogate the results of his observation, he will find, if he 
has had his attention aroused to the frequency of the diseases 
which simulate it, that he has met with this affection very rarely. 
Let it be borne in mind that as a complication of endometritis 
there is sufficient inflammation of the parenchyma to produce 
enlargement, puffiness, and sensitiveness, and that a differentiation 
of the affections, to be reliable, must be made with care. 

Varieties. — No varieties of acute metritis can be predicated as 
based upon the part of the organ attacked, for it is confined to 
no special portion, but affects the entire parenchyma from the 
cervix to the fundus. A distinction should, however, be made 
between the puerperal and non-puerperal forms, on account of 
their dissimilarity in frequency, severity of symptoms, prognosis, 
and terminations. 

Causes. — The chief causes for the disease in the non-pregnant 
uterus are : — 

Mechanical injuries from operations on the uterus, vagina, or 
bladder; excessive or intemperate cohabitation about the men- 
strual epoch ; the use of intra-uterine or vaginal pessaries ; 
dilatation of the cervix by tents ; the careless use of the uterine 
sound, or attempts at removal of growths from the body of the 
uterus. 

Sudden suppression of the menstrual flow. 

Endometritis, whatever be its cause; vaginitis, specific or 
simple ; or any other of those mentioned in the last chapter. 

Morbid growths in the parenchyma of the uterus, whether 
cancerous or fibroid. 



202 ACUTE METRITIS. 

Symptoms. — It is generally stated that the disease announces its 
invasion by a chill. In the cases which I have seen this has not 
been the fact, and should an attack be thus ushered in, I should 
strongly suspect cellulitis or pelvic peritonitis. In the beginning, 
violent pelvic pain, accompanied by vesical, rectal, and uterine 
tenesmus, comes on, sometimes with nausea, vomiting, and diar- 
rhoea. The pain soon becomes agonizing, extends down the 
thighs, and is very much increased by the passage of feces 
through the rectum. Should the complication of endometritis 
be present in any marked degree, a glairy, tenacious and gummy 
flow will appear, which rapidly becomes purulent and creamy. 
Should it not exist, no vaginal discharge will take place, unless 
the disease occurs during menstruation, when menorrhagia may 
show itself. All these symptoms will merely lead us to suspect 
the existence of metritis. The complete diagnosis will depend 
upon physical signs for its establishment. 

Physical Signs. — When pressure is made over the uterus great 
sensitiveness is found to exist. The finger introduced into the 
vagina discovers the organ lower than normal in the pelvis, the 
cervix enlarged and swollen, and the os dilated, and pressure upon 
the cervix gives great pain as it does also when practised against 
the body in the fornix vaginae. This last symptom is still more 
clearly developed by rectal touch and conjoined manipulation, 
which generally detect the body of the uterus pressing back upon 
the bowel. The passage of a speculum will generally be attended 
by so much pain that it will rarely be employed. Should it 
be introduced, the cervix uteri will be seen to be swollen and the 
os gaping. The vagina will be hot and dry, unless bathed with 
purulent material discharged in consequence of endometritis. 

Differentiation. — The disease must be differentiated from peri- 
tonitis, cellulitis, endometritis and active congestion. From 
the first two it will be known by mobility of the uterus, which 
would be fixed if they existed ; by sensitiveness being confined 
to the uterus and not existing over the pelvis, and by enlarge- 
ment and tenderness of the os and cervix. If the case be one 
of endometritis it will be known by the fact that the uterus will 
not be found markedly enlarged, nor so exquisitely sensitive upon 
pressure, the constitutional signs will not be so grave, and there 
will be the peculiar discharges marking this disease. From active 



TKEATMENT. 203 

congestion of violent character in its early stages, I know of no 
means of differentiation. The diagnosis must be determined by 
the subsequent progress of the case. 

Pathology. — The first stage of acute metritis is one of active 
congestion. The bloodvessels of the parenchyma become dis- 
tended, press upon the intervening nerves, and produce enlarge- 
ment of the uterus and pain. A blood stasis exists similar to that 
constituting the first stage of inflammation in other organs of the 
body. This is soon succeeded by the second stage, which consists 
in the exudation of organizable lymph, which being poured out 
into the interspaces of the muscular fibre rapidly becomes organ- 
ized, thickening the walls of the uterus and often indirectly pro- 
ducing displacement. It is very rare for suppuration to occur 
and abscesses to form subsequent to this as a third stage, though 
in a few exceptional cases such a result has taken place. One 
case of this character is recorded by Depaul and another by 
Scanzoni. 

Complications. — It may be complicated by inflammation of any 
of the tissues most proximate to it. Peri-uterine cellulitis, peri- 
tonitis, endometritis, cystitis, or rectitis, sometimes occurring. 

Course, Duration, and Termination. — Its course is not lengthy, 
recovery or a passage of the affection into the chronic form being 
generally arrived at in a fortnight or three weeks. 

Treatment. — As soon as the disease has been recognized the 
patient should be placed upon her back in bed and not allowed 
to leave it or to sit up upon any pretext, not even for evacuation 
of the bladder or rectum. Perfect rest should be insisted upon as 
an important element in the curative process. Warm poultices 
of flaxseed or corn meal should be laid over the hypogastrium, 
or instead of these towels wrung out of hot water and covered by 
oil silk may be used. Should these be inconvenient on account 
of weight, the artificial poultice called spongio-piline, which con- 
sists of a thick layer of wool and sponge woven together and 
covered by a thin layer of India rubber, may be made to replace 
them. A speculum should then be passed with great care, the os 
uteri plugged by a morsel of cotton, and a sufficient number of 
leeches applied to the cervix to abstract the amount of blood 
deemed advisable in the special case, or instead of this leeches 
should be applied to the perineum. Pain should be relieved by 



204 ACUTE METRITIS. 

opiates administered either by the mouth or rectum, or a supposi- 
tory of three grains of opium or one grain of extract of bella- 
donna may be deposited just within the cervix uteri. 

Under this treatment, combined with restriction to mild un- 
stimulating diet, the disorder will generally subside very rapidly, 
but great care should be exercised with reference to allowing the 
patient to resume her usual avocations, for carelessness in this 
respect may result in her becoming a sufferer from chronic metri- 
tis. For the purpose of preventing this, sexual intercourse, severe 
exercise, exposure during menstruation, &c, should be carefully 
avoided for some time after the apparent termination of the exist- 
ing affection. 

The practitioner should daily watch for the spread, of inflam- 
matory action to the pelvic areolar tissue. Should it be detected, 
a blister should at once be applied over the hypogastrium, pre- 
ceded, if it be thought advisable, by a few leeches. 



CHAPTEE XV. 

CHEONIC CERVICAL ENDOMETRITIS. 

When inflammation of acute character affects the uterus it has 
a marked tendency to invade the entire organ, and to involve 
both cervix and body, but with chronic inflammation this is not 
the case. Being of a lower grade of intensity, it more strictly 
confines itself to one tissue, either mucous or parenchymatous, 
and limits itself to the body or cervix. Such limitation is 
neither universal nor absolute, sometimes adjoining parts being 
more or less implicated and at others the entire organ being 
simultaneously and equally involved. 

Although it would be more in accordance with literary pro- 
priety and taste to describe, first, inflammation of the mucous mem- 
brane of the body and cervix, and then that of the parenchyma, it 
will prove more useful for the student whose familiarity with the 
subject is not great, to speak first of the diseases affecting the 
lower segment of the organ, and subsequently of those of the 
upper. Beginning, then, with inflammation of the mucous mem- 
brane, and subsequently taking up that of the parenchyma, we will 
study the morbid states of that portion of the uterus existing 
between the os externum and os internum, and, having accom- 
plished this, we will proceed to investigate those of the body of 
the organ. 

Definition. — By the term chronic cervical endometritis is 
meant chronic inflammation of the mucous membrane, extending 
from the os internum through the os externum and over the 
vaginal portion of the cervix uteri, as represented by the dotted 
lines in Fig. 68. 

Between inflammation affecting the vaginal surface of the cervix 
and that occurring within the canal there are many points of dif- 
ference ; so marked are they, indeed, that M. Nonat has boon in- 
duced to make two varieties of the affection. The disease may 



206 



CHRONIC CERVICAL ENDOMETRITIS 




be, and commonly is, confined to one of these parts. When it 
occurs on the vaginal face of the cervix, friction and other influ- 
ences often produce granular or cystic 
Fig. 68. degeneration ; and parenchymatous inflam- 

mation is more likely to occur from the 
same causes. In spite of this I deem it 
best to define the disease as I have done 
above, relying for completeness of descrip- 
tion upon a subsequent chapter devoted to 
what is commonly termed ulceration of 
the os uteri. 

Frequency. — Of all diseases of the geni- 
tal system of the female this is without 
doubt the most frequent, and although not 
in itself a malady of dangerous charac- 
ter, proves the starting point for some of 
the most serious and rebellious of uterine 
disorders. Exposed as the cervix uteri is 
to injury during coition, laceration from 
parturition and irritation from walking, 
riding, and lifting, it is not surprising that 
its complicated investment should frequently become the seat of 
disease. 

Synonymes. — It has been described under the names of cervical 
catarrh, cervical leucorrhcea, and endo-cervicitis. 

Normal Anatomy of the Cervical Mucous Membrane. — The cavity 
of the cervix uteri is a fusiform canal, measuring about one and 
a quarter inch, beginning at the os internum above and ending at 
the os externum below. 

Dr. H. Bennet lays great stress upon the fact that the division 
of the uterus into two cavities, accomplished by the os internum, 
is very complete. He objects to the diagram of Dr. Quain given 
in Fig. 69, and offers the representation in Fig. 70 as more correct. 
In the virgin uterus the internal os is represented by Dr. 
Bennet's diagram, while that of Dr. Quain more faithfully repre- 
sents that of the muciparous organ. The fact pointed out by 
Dr. Bennet attracted the attention of the ancients. 1 " Many of the 



The dots represent the site 
of chronic cervical endome- 
tritis. 



Tkeophilus, Com. on Hippocrates, Apb. ii. p. 469, Ed. Dietz. 



NORMAL ANATOMY 



207 



ancient authorities describe the uterus as consisting of two cavi- 
ties separated from one another by a membrane." On the ante- 
rior and posterior walls of the cervix are ridges, from which folds 



Fig. 69. 



Fig. 70. 





Dr. Quain's representation of the cavities 
of body and cervix. (Quain.) 



Dr. Bennet's representation of uterine 
and cervical cavities. (Bennet.) 



are given off which are arranged with regularity, and run obliquely 
upwards and outwards, to end in other indistinct lines on the 
sides of the canal. (Fig. 71.) This arrangement of mucous mem- 
brane has received the name of arbor vitae. 

Between these folds numerous mucous glands are seen, which 
are called the glands of Naboth. Dr. Tyler Smith 1 estimates that 
a well developed virgin cervix probably contains at least ten thou- 
sand of these follicles. The mucous membrane forming these folds 
or rugae is covered over by cylindrical and ciliated epithelium and 
studded by villi, which are found in considerable numbers upon 
the larger rugae and other parts of the mucous membrane. (Fig- 72.) 



1 On Leucorrhcea, Am. ed., p. 38. 



208 CHRONIC CERVICAL ENDOMETRITIS, 

Fig. 71. 




One of the four longitudinal columns of rugae from the virgin cervix. Nine diameters. 

(T. Smith.) 

The natural secretion of the cervical canal has been shown by 
Mr. Donne to be alkaline, unlike that of the vagina, which is acid. 

Fig. 72. 




Villi of canal of the cervix uteri, covered hy cylindrical epithelium and containing looped 
bloodvessels. One hundred diameters. (T. Smith.) 



PATHOLOGY — CAUSES. 209 . 

Pathology, — Cervical endometritis consists in inflammation of 
all this structure and consequent alteration of its condition. The 
glands of Naboth are especially involved in the morbid action, 
the disease chiefly consisting in glandular inflammation. The 
large amount of glairy mucus which is secreted as one of its 
symptoms is the characteristic discharge of these structures. 
Looked at with a strong glass in post-mortem examinations, they 
are seen enlarged and elevated, and, according to Aran, 1 their 
mouths may be seen very much dilated. But the affection does 
not confine itself to these follicles for a long time. Yery soon 
the villi or papillas, especially those on the vaginal face of the 
cervix, become diseased. At first there is a want of the normal 
supply of epithelium which produces a slight and very superficial 
abrasion. This becomes in time more distinct and marked, from 
destruction of the villi themselves over spaces of greater or less 
extent. If this process of destruction went on and affected the 
deeper tissues, a true ulcer would be formed and no one would 
ever have denied the name of ulceration to the existing condition ; 
but it does not thus progress. In time an hypertrophy occurs 
in the villi, which increase in size, project like so many hairs 
from the surface, and give to the os and cervix an appearance 
which has caused the term granular degeneration to be applied to 
it. This, state affects the vaginal portion of the cervix chiefly, 
but may extend up the canal. 

On the vaginal portion of the cervix are sometimes found muci- 
parous follicles similar to those existing in the cervical canal. 
These often enlarge, fill with honey-like fluid, and, bursting, give 
rise to follicular ulceration. 

Another pathological state, which is occasionally met with as 
a result of cervical endometritis, is an eversion of the os and 
lower portion of the canal to such an extent as to keep up inflam- 
mation there by the friction of the membrane, thus exposed, 
against the floor of the pelvis. Some very obstinate cases are due 
to this condition. 

Causes. — It may result from any influence which does mechani- 
cal injury to the os and cervix, as displacement of .the uterus so 
that locomotion or muscular effort may force it against the pelvic 

> Mai. de l'Uterus, p. 423. 

14 



210 CHRONIC CERVICAL ENDOMETRITIS. 

walls, excessive coition, the use of pessaries, the parturient pro- 
cess, and efforts at preventing conception or producing abortion ; 
anything specifically exciting inflammation, as exposure to cold 
and moisture, particularly during menstruation ; or it may occur 
from vaginitis; constriction of the canal, resulting in the forma- 
tion of clots in the menstrual blood which at intervals during 
menstruation are forced out by contractions of the uterus ; the 
existence of small polypi in the cervix; fissures or slits in 
the lower portion of the canal. Many other causes might be 
enumerated, but these are they which are most commonly produc- 
tive of it. 

Symptoms. — Cervical endometritis may exist for a length of 
time without presenting any symptoms of sufficient gravity to 
warn the patient of its presence. In the great majority of cases, 
however, it will not continue long without announcing its exist- 
ence by some or all of the following signs. The first symptom 
which will attract attention will probably be dragging sensations 
about the pelvis. These will soon be followed by pain in the 
back and loins, which will be very much increased by exercise or 
muscular effort. Then a more or less profuse leucorrhcea will be 
noticed, the discharge as it issues from the vulva resembling 
boiled starch or thick gum-water and often irritating the vulva 
and vagina to such an extent as to produce inflammation in them. 
Menstrual disorders will now show themselves. The discharge 
will be either too scanty or too profuse, too frequent or too infre- 
quent, and to a certain extent painful, although decided dys- 
menorrhea from disease strictly confined to the cervical mucous 
membrane is not common. 

Before the disease has existed for a long period the constitution 
of the patient will show signs of becoming implicated. She will 
become nervous, irascible, moody, and often hysterical. Her 
appetite will diminish and digestion grow feeble, so that impover- 
ished blood will soon be observed as a result of impaired nutrition. 
With some or all of these signs of the existing disorder the 
patient may continue for a length of time without suffering from 
others of more annoying or graver character. Complications may, 
however, rapidly develop themselves ; cystitis, cervical metritis, 
and corporeal endometritis coming on and proving exceedingly 
troublesome. At times pain during sexual intercourse constitutes 



PHYSICAL SIGNS'. 211 

a prominent sign of cervical disease, but it belongs rather to cer- 
vical metritis than to endometritis; the former having added itself 
as a complication to the latter and thus produced the symptom. 
Sometimes nausea, and even vomiting, present themselves as 
symptoms, and these, together with the digestive disorder before 
mentioned, produce so great a deterioration in the nutrition of the 
patient as to result in emaciation, excessive paleness, and loss of 
muscular power and capacity for endurance. 

Although these symptoms are enough to make us confident of 
the existence of uterine disorder, they by no means furnish reliable 
grounds for a positive diagnosis. This can be arrived at only by 
physical exploration. 

Physical Signs. — The patient being placed upon her back, and 
the finger of the examiner introduced into the vagina, the os uteri 
will probably be found in its usual position in the pelvis, for the 
weight of the uterus is not increased, the parenchyma being un- 
involved. The os may be somewhat enlarged and its lips slightly 
puffed, or it may be roughened on account of granular degenera- 
tion of its papillary structure. Sometimes, however, severe cer- 
vical endometritis may exist without any enlargement of the os, 
or any trace of abrasion or granular degeneration. If the finger 
be now placed under the cervix and that part raised by it, pain 
will be complained of, though not to any great extent. This will 
be most marked near the os internum. No other affirmative sign 
can be elicited by this means, and the speculum should then be 
used. By this the os will be found to be in the condition recog- 
nized by touch, and from it will be seen to exude a long string of 
tough, tenacious mucus which will closely resemble the white of 
egg. If entangled by a small mass of cotton attached to the end 
of a whalebone rod, this will be found so strong and resisting that 
it cannot be drawn from the canal. It will resist even a stream 
of water thrown with some force upon it, and very often is re- 
moved only after several efforts by this or other means. The 
cervix will usually be found not to be enlarged. Its tissue may 
present a swollen, puffed appearance, or be intensely red as if in 
a state of ulceration, which will upon close inspection be found 
due to removal of its investing epithelium and the occurrence of 
a granular degeneration. Should this condition exist, it will afford 
relief to the mind of the inexperienced Gynecologist for the diag- 



212 CHRONIC CEKVICAL ENDOMETRITIS. 

nosis of the case will be clear. But another state of things may 
be discovered which will leave him in doubt. Upon removing 
the plug of obstructing mucus he may discover no evidence of 
disease. The os is no larger than it should be, its tissue is not 
reddened, no ulceration exists, in fact nothing is found explain- 
ing the backache, nervousness, emaciation, and profuse leucorrhoea 
which led him to advise and urge the examination. The case 
is simply one of cervical endometritis which affects the inner and 
upper parts of the canal without involving the os and lower 
extremity, or the disease is corporeal and not cervical. 

Differentiation. — We will suppose the diagnosis of cervical endo- 
metritis to be made ; there are several questions to be decided 
before it should be considered complete. First, it must be settled 
whether the morbid state is confined to the cervix or extends into 
the body. Second, whether if confined to the cervix it is limited 
to the mucous lining of that canal or extends to the parenchyma. 
If the symptoms are no more severe than those already mentioned, 
more especially the constitutional signs, it may at least be re- 
garded as probable that the membrane of the body of the organ 
is free from disease. If the patient be a virgin, it is much more 
likely to be corporeal than cervical disease, while if she has borne 
children it is much more likely to be cervical than corporeal. 
More reliable testimony than this may be obtained from the use 
of the uterine probe, which should now be employed. The exami- 
nation by touch has taught us the position of the uterus; now, 
bending the probe so as to give it a curve proper for entrance into 
its cavity we pass it gently in. If the disease be confined to the 
cervix the instrument will meet with obstruction at the os inter- 
num, which will be dilated in case the affection has advanced be- 
yond it, a fact which has been specially insisted upon by Dr. 
Henry Bennet. Passing the probe into the cavity of the body, it 
should be carried up to the fundus, which should be gently struck 
by it. Then it should be made to impinge with a slight degree 
of force upon the sides of the cavity. If the body be affected, this 
will give pain which may last, as a patient once expressed it, 
u like a toothache," for half an hour, and the removal of the instru- 
ment will very likely be followed by a flow of mucus and probably 
by one or two drops of blood. 

Should the disease be cervical, no pain will result from the ex- 



PROGNOSIS — TREATMENT. 213 

ploration, and the removal of the probe will be followed by the 
escape neither of mucus nor blood, unless improper force be 
applied. 

Course, Duration, and Termination. — Cervical endometritis is not 
a self-limiting disease, and consequently its duration will depend 
upon circumstances which control its progress. It may unques- 
tionably be recovered from without medical aid. Any alterative 
influence which exerts a complete change in the economy, as, for 
instance, parturition, entire alteration of the habits of life, or some 
similar combination of circumstances, sometimes results in a cure. 
But it is certainly safe to say that, unchecked, it might pass, slowly, 
perhaps, but still steadily, into disease of the parenchyma, which 
would probably draw in its train hypertrophy, displacement, and 
all the long list of ailments which make the lives of women 
suffering from uterine disease so burdensome. 

Prognosis. — The prognosis of the disease is always favorable if 
proper treatment be adopted ; but great caution should be observed 
as to fixing the time at which recovery will occur. Even in the 
mildest case which has lasted for some time, from four to six 
months will probably elapse before perfect cure can be accom- 
plished, and even after this a relapse will be very likely to occur 
unless preventive measures be adopted and strictly adhered to. 
The prognosis will of course depend for its correctness upon that 
of the diagnosis, for if parenchymatous complication exists, or the 
morbid action has affected the lining membrane of the body, an 
equally favorable prediction cannot be made. 

Treatment. — The disease consisting in endometritis and not me- 
tritis, the efforts of the practitioner must be directed to producing 
an alterative influence upon a mucous membrane which is in a 
condition of chronic inflammation, and the prevention of all influ- 
ences which may cause it to spread to the muscular structure 
beneath. These ends will be best accomplished by the following 
means : — 

General regimen ; 
Emollient applications; 
Alterative applications. 

General Regimen. — " The first care of the practitioner/' says Sir 
Charles Clarke, ''should be to remove, if possible, the causes of 
the disease. * * * Women who live in a moist atmosphere, 



214: CHRONIC CEEVICAL ENDOMETRITIS. 

who keep bad hours, who spend much of their time in bed, or 
who inhabit hot rooms (being generally weak women, and having 
a relaxed vagina), will be apt to be affected by the complaint." 
All such unfavorable circumstances should be modified. Should 
any depressing influence, such as lactation, any habitual discharge, 
or cause for mental anxiety be discovered, it should be carefully 
removed and the patient, unless absolutely plethoric, be put upon 
the use of vegetable tonics, the mineral acids and preparations of 
iron. The functions of the alimentary canal should be constantly 
supervised. The diet should be mild, unstimulating, and nutri- 
tious. But no system of starvation should be entered upon for 
the tendency of the disease is to the production of spanaemia, and 
this we should combat. All spices, and aromatic and stimulating 
condiments should be avoided. Every day, unless some special 
contra-indication should exist, the patient should take fresh air 
and exercise, by carriage or on foot for a time which should be 
limited by the circumstances of the particular case. If she should 
be unable to do this from any cause, she should be thoroughly 
protected and the pure air, even in winter, be allowed to circulate 
freely in her chamber, all the doors and windows of which should 
be opened, for two or three hours daily. This plan, which is sug- 
gested by Prof. Byford, of Chicago, I have found a most excellent 
one. The bowels should be kept regular by saline cathartics, and 
the skin in proper state by occasional baths. Care must be ob- 
served not to depreciate the strength by catharsis, and to prevent 
this a ferruginous tonic may be advantageously combined with 
the saline as in the following mixtures : — 

R. — Magnesiae sulphatis, gij. 
Ferri sulphatis, gr. xvj. 

Acidi sulphurici dil. ^j. 
Aquae, Oj. — M. 

One ounce (two tablespoonfuls) in a tumbler of iced water every morning 
upon rising. 

R. — Sodas et potass, tart. ^ij. 

Vini ferri amari (U. S. D.), ^ij. 
Acidi tartarici, ^iij. 

Aquae, 3xij.— M. 

One ounce in a tumbler of iced water every morning upon rising. 



ALTERATIVE APPLICATIONS. 215 

Should one draught not be sufficient, two, or even three may be 
taken daily, for the result will prove tonic and reparative as well 
as cathartic. 

If much disturbance of the nervous system should exist, the 
bromide of potassium in doses of from fifteen to twenty grains, 
three times a day, will be found very useful. 

Emollient Applications. — The cervix should be irrigated every 
night and morning, by warm water thrown against it by the plan 
recommended on page 229. To the water may be added glycerine, 
boiled starch, infusion of linseed, slippery elm, or tincture of opium. 
The irrigation should be so planned as to last for twenty or thirty 
minutes without fatiguing the patient or proving a source of 
annoyance to her. The method for doing this is so fully described 
elsewhere that it need not be repeated here. 

Alterative Applications. — The local treatment by means of appli- 
cations made through the speculum will, with great advantage, 
be preceded by dilatation of the whole cervix by means of a tent 
of sponge or sea tangle. This not only exposes the canal to appli- 
cations, but opens the way for escape of fluids, and by pressure 
exerts an alterative influence on the diseased membrane. Should 
granular degeneration exist, it will be peculiarly applicable. The 
tent being removed the canal should be cleansed of blood and 
mucus, which may be done by a small pledget of cotton wrapped 
around a staff of whalebone, hickory, or bamboo, eight inches 
long, as thick as a pipe-stem, and tapering toward its extremity. 
Should the first pledget become saturated, it can readily be slipped 
from the staff and another wrapped in its place, or several staves 
may be prepared and kept ready for use. This answers a much 
better purpose than sponge, which is too expensive an article to 

Fig. 73. 



Rod eight or nine inches long, wrapped with cotton. 

be thrown away, and if used, even after careful washing, may con- 
vey infectious material from one patient to another. A little prac- 
tice will be necessary to enable one to arrange the cotton upon 
the staff in a proper manner. 

Another method of cleansing the cervix and cervical canal, 



216 CHRONIC CERVICAL ENDOMETRITIS. 

and one which I prefer to that just mentioned, consists in the use 
of a syringe with a nozzle four or five inches long, which may be 
worked by one hand. The thumb retracting the piston, while 

Fig. 74. 



Syringe for cleansing the cervix and vagina. 



two fingers hold the body of this instrument, it is filled with 
water, which is thrown with violence against the os and cervix, 
the tip of the nozzle being in direct contact with the part to be 
cleansed. The fluid thus ejected collects in the speculum if a 
cylindrical instrument be used, in the vagina if Sims's speculum 
or one of its varieties be employed. It is again taken up and 
projected against the cervix, and this is repeated until the part is 
sufficiently cleansed. I am thus particular in speaking of the 
process of cleansing the cervix, because I believe that treatment 
is often impaired in its efficacy by a neglect of it. The caustic 
used being neutralized by a thick envelope of coagulable mucus, 
is prevented from exerting a decidedly alterative influence upon 
the diseased part. Care must be taken not to throw the fluid into 
the body of Ifhe uterus, but even should this occur after dilatation, 
it will at once escape. The cervix can now be clearly seen and 
applications made. 

It is a fact, admitted in every department of pathology, that 
certain substances of greater or less strength as escharotics have 
the property, when applied to inflamed mucous surfaces, of so 
modifying the morbid action existing in them as to diminish its 
intensity and in time to check its progress. It is upon this prin- 
ciple that chronic inflammation of the fauces, urethra, bladder, 
and many other mucous surfaces are treated. Those substances 
which have been found by experience to answer the best purpose 
in inflammation of the mucous lining of the cervix are the follow- 
ing : nitrate of silver, iodine, chromic acid, carbolic acid, sulphate 
of copper, solution of persulphate of iron, tannin, and acetate of 
lead. After the tent has been removed and the cervix cleansed, 
a brush composed of cameFs hair, or, better still, of delicate bris- 
tles, is dipped in one of the substances mentioned, dissolved in 
water. If copper, zinc, or lead is employed, the solution may be 



ALTERATIVE APPLICATIONS. 217 

made saturated, and if tannin is used it may be dissolved in glyce- 
rine in large amounts. The whole cavity of the cervix is painted 
over thoroughly with the solution, from the os internum to the 
vaginal mucous membrane. After this application a bit of 
cotton, with a piece of stout thread attached, should be dipped 
in glycerine and applied against the cervix. This protects the 
vagina from contact with the drug, and, as Dr. Sims has shown, 
acts as a local hydragogue, depleting the part to which it is 
applied. 

This may be repeated once a week, the application being pre- 
ceded each time by the tent, which should never be allowed to 
remain longer than twenty-four hours. 

It is difficult to give any rule with reference to a choice of these 
alterative applications. All that can be said is that it is indicated 
by the same rules which govern a selection when employed else- 
where in the economy. In choosing the caustic the practitioner 
should bear in mind that one great objection to those of severe 
character is the liability of their closing the cervix by causing 
cicatricial contraction. For this reason I would never, unless to 
destroy a malignant growth, or cause contractions in an inverted 
cervical canal, introduce within the os externum, or apply nearer 
than three or four lines from its edge, the actual cautery or the 
acid nitrate of mercury. In the use of the solid nitrate of silver, 
even, one should be cautious and limit its application to cases in 
Avhich the canal is dilated. Chromic acid, which was, I think, 
introduced into uterine practice by Dr. Marion Sims, possesses 
the great advantage of not contracting the neck. At least I 
should say that I have never seen nor heard of a case in which it 
did so. The fluid preparation in general use is a saturated solu- 
tion, though it may be used of any strength desired. The plan 
just described involves keeping the patient in bed only for twenty- 
four hours out of every week, while the tent is in place, and cer- 
tainly shortens the course of the affection very much. 

Another means of making applications to the whole cervical 
canal, either after or without dilatation by tents, is the following : 
the uterine probe being passed up to the os internum and with- 
drawn, its curve shows the direction to be followed by the instru- 
ment by which the application is to be made. This consists of a flat 
silver probe, measuring with its handle about eight or ton inches. 



218 CHRONIC CERVICAL ENDOMETRITIS. 

It is decidedly the best instrument for the purpose in view with 
which I am acquainted, and was introduced into practice by Dr. 
Emmet, of this city. It resembles very closely the uterine probe, 
the only difference being that it is flat and has no terminal bulb. 
Fig. 75, constructed after a plan adopted by Dr. Sims, represents 
a slight modification of this instrument. Two inches of the ex- 
Fig. 75. 



— 



a. neMAAOttca 
Silver probe with slide. 



Fig. 76. 




Same instrument with cotton wrapped around it and thread attached. 

tremity of this are wrapped with a very thin film of cotton, the 
arrangement of which, although it appears quite simple, requires 
a little practice, and the probe is bent to the curve of the uterine 
probe which was lately passed to the os internum. It is now 
dipped in a solution of chromic acid, nitrate of silver, or saturated 
tincture of iodine and passed up to the os internum, where it is 
kept for one or two minutes and then withdrawn. A stream of 
water should then be projected on the cervix to remove any sur- 
plus which may have escaped and the application be repeated. 
This repetition is advisable because the first application sometimes 
only coagulates and removes tenacious mucus which remained in 
the upper part of the canal, and a second is required to really 
cauterize the surface. This instrument may be likewise employed 
so as to leave a long thin roll of cotton in the canal. The flat rod, 
being wrapped with this substance, is dipped in a solution of 
alterative or astringent character. It is then carried up to the os 
internum, the cotton is slipped off by the slide and remains in the 
cervical canal. By the thread attached it may be removed in 
twelve hours. Instead of dipping the cotton in a solution it may 
be prepared in this manner and applied dry. An ounce of the 
sulphate of copper, zinc, or iron may be dissolved in a pint of 



ALTERATIVE APPLICATIONS. 219 

water. In this, a mass of cotton is soaked, then dried in the sun, 
and it is ready for nse. Or the cotton may be saturated with 
iodine and glycerine, as recommended by Dr. Greenhalgh, and 
employed in the same manner. 

Another convenient method for reaching the upper parts of the 
canal is by the use of a very delicate probe of hard rubber about 
eight inches long, the invention of Prof. C. A. Budd, of New York. 

Fig. 77. 



Budd's elastic probe. 

This instrument is wrapped with cotton as is Dr. Emmet's, and so 
delicate is it that when introduced straight into the cervical canal, 
it passes along its curve and goes directly to the fundus. Hold- 
ing it over the flame of a lamp for a few seconds will cause it to 
become pliable as a. willow twig, when it may be bent as desired, 
and when it becomes cool it keeps the curve given it until heated 
again. These two probes leave nothing to be desired in making 
fluid applications. In applying the solid caustics to the walls of 
the canal a different method should be pursued. Should the case 
appear to require a solid caustic the nitrate of silver may, with 
great advantage, be employed, though the means generally adopted 
for applying this substance are inefficient. If a straight stick of 
lunar caustic is fixed in a quill or held in the bite of a pair of 
forceps and passed into the os, by no possibility can the procedure 
accomplish what is desired. It may cauterize and will probably 
do so with objectionable thoroughness, a quarter or half an inch 
of the lower portion of the canal, but how can it be expected to 
go upwards for an inch and a quarter and come in contact with the 
whole surface inflamed, a surface remarkable for its inequalities and 
convolutions. Sir Benjamin Brodie many years ago, according to 
Dr. Barnes, of London, advised fusing nitrate of silver and allow- 
ing it to cool upon the tip of a probe for cauterizing sinuous 
tracts, and Chassaignac, of Paris, applied the same substance to 
the cavity of the womb by coating platinum wires with it. Within 
the last four years Dr. F. D. Lente, of Cold Spring, X. Y., has 



220 CHRONIC CERVICAL ENDOMETRITIS. 

experimented extensively in reference to this subject, and the 
result of his investigations has been to furnish the profession with 
the best and most reliable of all the means at our command for 
applying solid lunar caustic to the mucous lining of the uterus. 
Other methods which have been suggested and employed are 
these : the use of Lallemand's porte caustique ; leaving a pellet 
of nitrate of silver in the uterine cavity to dissolve ; carrying up 
a small piece held in a delicate wire casing, &o. &c. ; but none of 
these compare with Dr. LentS's, which is thus practised. A probe, 
shaped like the ordinary uterine probe, is warmed and then clipped 
in a little platinum cup which contains nitrate of silver which has 
been fused over a spirit lamp. Eemoving the probe after dipping 
it, and waving it for a few seconds, a film of the nitrate will be 
found to have covered it. It may then be again dipped, and the 

Fig. 78. 



Lente's silver caustic probe. 




process repeated until a sufficiently large pellet is made to cover 
the tip of the instrument. Figs. 78 and 79 represent the probe 
and cup. 



Fig. 79. 



Lente's cup for fusing nitrate of silver. 

It is used thus : the cervical canal having been cleansed of 
mucus, and its direction learned by the ordinary probe, Lente's 
probe is passed up and rubbed against every part of its investing 
membrane, and dipped as carefully as possible into its convolu- 
tions before its removal. After all such applications, a stream 
of water should be projected against the cervix and a pledget of 
cotton, which has been freely saturated with glycerine, with a 
bit of packthread attached, should be placed against it. By 



ALTERATIVE APPLICATIONS. 221 

means of the thread this may be removed by the patient in twelve 
hours. It is a question of some importance to decide how often 
these caustic applications should be repeated. As a general rule 
I should say once a week, except in the case of a thorough appli- 
cation of chromic acid or the solid nitrate, when twice that time 
should be allowed to elapse. These cause decided sloughs to oc- 
cur, after the removal of which it is better to dress the surfaces 
left uncovered, by equal parts of glycerine and solution of the per- 
sulphate of iron, or by tincture of iodine, or weak solutions of the 
nitrate of silver left in the canal upon rolls of cotton. 

Another excellent plan of treating this affection is by the use 
of medicated tents of sponge. For the past six months I have 
employed it very generally, and now prefer it to any other mode 
of treatment. Tents of this character may be prepared in two 
ways. The sponge may be wound upon a large wire which will 
leave a capacious canal. This may be filled, after the tent is dried, 
with a long suppository of cocoa butter containing nitrate of silver, 
iron, or any other mineral in admixture. As the tent expands it 
is permeated by the elements contained in the suppository, which 
thus come in contact with the walls of the uterus. Another me- 
thod is this : sponge cut into proper shape is saturated for a length 
of time in solutions of zinc, copper, iron, iodine, carbolic acid, or 
lead. They are then squeezed, dried, soaked in a solution of gum 
acacia, and made into tents. They possess not only the alterative 
powers attached to the pressure which they exert, but bring into 
direct contact with the diseased surface alteratives of most reliable 
character. The influence of this means is unquestionably good ; 
it produces no more pain than the use of the non-medicated tent, 
and all offensive odor is prevented in the sponge. 

Instead of medicated sponge, a caustic or an alterative may be 
incorporated with butter of cocoa, gum tragacanth, or some simi- 
lar substance, made into suppositories two inches in length, and 
left in the cervical canal. Into these cervical suppositories may 
be introduced zinc, copper, iron, lead, or bismuth, with opium, 
conium, or hyoscyamus. They do not compare in efficiency with 
medicated tents, and it is difficult to keep them from becoming 
dislodged. 

To keep in mind the plans recommended for applying caustics 



222 



CHRONIC CERVICAL ENDOMETRITIS. 



and alteratives to the cervical canal the following resume will 
prove "useful : — 

1st. Dilatation by tents ; 

2d. Application of fluids by small brushes ; 



3d. 


a 


" by flat probe ; 


4th. 


(< 


" by rolls of cotton ; 


5th. 


u 


of solids by Lente's probe ; 


6th. 


11 


" by medicated tents 


7th. 


11 


" by suppositories. 



CHAPTEE XVI. 



CHEONIC CERVICAL METRITIS. 



Fig. 80. 



Definition. — This affection consists in inflammation of the 
parenchyma of the cervix uteri, whether occurring alone or as a 
complication of cervical endometritis. 

It has been described under the names of engorgement, hyper- 
trophy, inflammatory hypertrophy, and 
chronic cervicitis. 

Causes. — The causes may be thus enu- 
merated : — 

Parturition or abortion ; 

Injuries ; 

Excessive sexual indulgence ; 

Pessaries ; 

Displacements ; 

Cervical endometritis. 
It generally originates from parturition 
or abortion, and hence is exceedingly 
rare in the nulliparous woman, though 
it may arise from injury, the result of 
operations, sexual intercourse, badly fit- 
ting pessaries, or friction from displace- 
ment of the uterus. I have seen it occur 
in a number of cases as a consequence 
of cervical endometritis, inflammatory 

action passing from the mucous membrane to the subjacent 
parenchyma. It must not be supposed that it is to be looked for 
as an early or constant result of the last-named disease, which 
often continues for a long time without inducing it, but in ex- 
ceptional instances it is unquestionably thus established. 

Symptoms, — The disease shows itself by pain in the back and 
loins, pressure on the bladder or rectum, painful and excessive 




The dots represent the site of 
cervical metritis. 



224 CHRONIC CERVICAL METRITIS. 

menstruation, difficulty of locomotion, nervous disorder, pain 
during sexual intercourse, dyspepsia, headache, and a general 
sense of lassitude and debility. If no disease of the mucous 
lining exist, there will be no leucorrhoea ; but as this is usually 
present it is very commonly a prominent symptom, and should 
granular degeneration exist, the leucorrhoeal discharge will often 
be tinged with blood. 

Physical Signs. — Yaginal touch will generally discover that 
the uterus has descended in the pelvis so that its cervix will rest 
upon the floor of it. The cervix will be found large, swollen, 
and painful, and the os may admit the tip of the finger. If the 
finger be placed under the cervix and it be lifted up, pain will be 
at once complained of, and if it be introduced into the rectum 
so as to press upon the cervix as high as the os internum it 
will often reveal an exquisite degree of sensitiveness. Under 
these circumstances the position of the uterus will generally be 
found to be abnormal. The cervix will in some cases have moved 
forwards and the body backwards, or the opposite change of 
place may have occurred. 

Course and Termination. — It is astonishing to what an extent 
enlargement of the cervix as a result of parenchymatous inflam- 
mation will go. Sometimes this part will equal in size a very 
small orange, and, filling the vagina, will compress the rectum 
quite forcibly, so as in a great degree to close its canal. Left to 
itself the disease has no limit, but sometimes passes away leaving 
the cervix enlarged and very soft and flabby, or very hard and 
nodulated. At other times an absorption of effused material 
occurs, and the cervix becomes small, hard, and indurated. 

Pathology. — According to the formerly accepted view, the fol- 
lowing .changes were supposed to occur. In the first stage the 
cervical parenchyma was regarded as gorged with blood, a state 
of active congestion existing. This was supposed soon to pass 
into the second stage, consisting in an effusion of lymph, when, 
unlike a similar process in other parts, the morbid action ceased 
or rather did not advance, and unless relieved by treatment, con- 
tinued stationary for a length of time. The third stage of in- 
flammation in other parts, that of suppuration, was admitted to 
occur rarely here, or in the parenchyma of the body, and in 
time all inflammatory action ceasing, the cervix remained large 



PEOGNOSIS. 225 

and indurated without sensitiveness, or the effused lymph may be 
absorbed, and great diminution in size occur with induration. 

Eecently, Scanzoni, Klob, and other pathologists, have 
ascribed the hypertrophic enlargement attending the disease to 
congestion and a proliferation of the areolar tissue of the part. 
This produces engorgement, sensitiveness, increase of weight, 
and induration. It is highly probable that the second of these 
theories offers the true explanation of the results of disease in 
this part, and that the former was adopted more in consequence 
of analogical reasoning than of pathological investigation. It 
is probably for this reason that pregnancy is found to be so 
prolific a source of the affection, that condition furnishing the 
tendency to rapid growth of connective tissue, which constitutes 
its chief element. 

Differentiation. — The only point to settle before the diagnosis 
can be considered complete, will be whether the cervix alone is 
affected, or whether its enlargement is only a part of a general 
uterine development from disease. To determine this question, 
two means are at command ; first, the examiner introducing one 
or two fingers under the body of the uterus, and depressing the 
abdominal walls by the other hand so as to clasp the fundus, 
ascertains whether it is larger than it should be, or of normal 
size and free from sensitiveness. He then passes the uterine 
probe into the cavity of the body, and measures it. If the uterine 
cavity is increased in size, the evidence is in favor of the disease 
having extended to the parenchyma of the body. Should its 
size be normal, this is probably not the case. 

By means of the probe, the walls of the uterus should then be 
struck to test the existence of pain. Should pain last for some 
time after the removal of the probe, it is probable that the pa- 
renchyma of the body is affected ; should it not exist at all, the 
evidence is against that supposition. 

Prognosis.— In this affection, as in all others of the uterus, the 
prognosis will depend in a great degree upon the patient. If she 
be unwilling to sacrifice her inclinations and pleasures, but half 
fulfils the directions of the attending plrysician, and clandestinely 
exposes herself to prejudicial influences, the treatment will accom- 
plish nothing. In the case of a reasonable patient, who appre- 
ciates what is at stake, and is anxious to regain her health, it may 
15 



226 CHRONIC CERVICAL METRITIS. 

be regarded as favorable, though, the reduction of a large cervix 
may require a great deal of time, many months being often neces- 
sary to accomplish it completely. 

Complications. — Cervical metritis may give rise to many and 
serious complications, as displacements, cystitis, rectitis, and cellu- 
litis, which may greatly annoy and discourage the patient. 

Treatment. — In the treatment of the disease under consideration 
the same principles should guide us as in similar inflammations 
elsewhere, the special means at command being : — 

Eest ; 

General regimen ; 

Depletion ; 

Emollient and sedative applications ; 

Alterative applications ; 

Counter-irritation. 
Rest. — The patient should be instructed to take much less ex- 
ercise than usual, to lie upon her bed or lounge for several hours 
during the day, and to remain in bed during menstrual periods. 
Judgment should be exercised about confining her to her bed 
continuously, for many women become restive under the confine- 
ment, and suffer both in mind and body, the sanguineous and 
nervous systems being impaired by want of fresh air. If the 
parenchyma be much affected so that the cervix is painful upon 
pressure, absolute rest upon the back should be insisted upon. 
Should she not remain in bed, in order to prevent friction of the 
inflamed part against the floor of the pelvis, she should be espe- 
cially guarded against lifting weights and climbing ascents, and 
the clothing should be worn very loose around the waist and sup- 
ported by suspenders or skirt supporters upon the shoulders. 
Sexual intercourse during the existence of this disease must 
necessarily be productive of evil, and should be interdicted. There 
is only one method, as a general rule, by which this can be accom- 
plished, and that is by the separation of husband and wife. If 
this is impracticable, let an injunction of excessive caution be 
substituted for total abstinence, which will be almost certainly 
disobeyed. By these means we do all in our power to place the 
inflamed part at rest as we would a fractured bone or inflamed 
testicle. 



DEPLETION. 227 

General Regimen. — The strength should be sustained by mild, 
though thoroughly nutritious food, and everything of an exciting 
nature should be avoided. The bowels should be kept in natural 
condition, and the state of the sanguineous and nervous systems 
maintained by fresh, pure air and moderate exercise. As this 
subject has been fully dealt with in the last chapter, the reader 
is referred to that in order to avoid repetition. 

Depletion. — General bloodletting is now almost universally 
abandoned in the treatment of chronic diseases of the female 
genital system, although M. Nonat, a most excellent modern au- 
thority, and some others, still advise it in corporeal metritis. So 
marked is the tendency to spanaemia in all uterine affections that 
I cannot but regard the practice as highly pernicious. The three 
methods by which local depletion of the cervix can be best prac- 
tised are leeching, scarification, and cupping. In such a case as 
that which we are considering three or four large leeches, or a 
sufficient number of small ones, to take from three to five ounces 
of blood, may be applied in the following manner. A cylindri- 
cal speculum, of sufficient size to contain the entire vaginal por- 
tion of the cervix, being passed and the part thoroughly cleansed, 
a small pledget of cotton, to which a thread has been attached for 
removal, should be placed within the os, so as to prevent the 
entrance of the leeches to the cavity above. A few slight punc- 
tures, sufficient to cause a flow of blood, should then be made 
in the cervix and all the leeches to be applied thrown in, and 
the speculum filled at its extremity by a dossil of cotton pushed 
toward the bleeding surface. The speculum should be watched 
until they cease sucking, for if left for a very short time, even 
with the mouth of the instrument filled with cotton, they will 
escape. After their removal all clots of blood should be removed 
by a rod with cotton attached, the speculum withdrawn, a large 
sponge squeezed out of warm water placed over the vulva, and the 
patient directed to remain perfectly quiet. Should there be great 
pain upon pressing the cervix, or should the leech-bites give ex- 
cessive pain, as they sometimes do, they should in future be 
applied by preference to the perineum. Should scarification be 
employed, a very sharp and narrow bistoury or tenotomy knife 
should be introduced within the os, and drawn outward towards 
the vaginal edges of the cervix so as to sever all the superficial 



228 CHRONIC CERVICAL METRITIS. 

vessels over which it passes. I am in the habit of employing, in 
preference to the latter, acupuncture, which may be performed by 
an ordinary three-sided surgical needle held in the grasp of a pair 
of forceps, or, still better, by a little spear, the invention of Dr. 
Buttles, of this city. 

Fig. 81. 



Buttles's spear-pointed scarificator. 

This little instrument, when plunged about one-sixteenth of an 
inch into the cervix and given a rapid half turn before-removal, 
causes a very free flow of blood should congestion exist. If a 
sufficient flow does not occur from three or four of its punctures, 
this can be caused by dry cupping the cervix by a very simple 
instrument, made of hard rubber, which is introduced through the 
speculum, the medium size of the cylindrical variety being large 

Fig. 82. 




s. riEKAm-eoi 
Hard rubber cylinder for dry cupping the cervix uteri. 

enough to admit it. Being passed up to the cervix, the piston is 
retracted, and so perfect is the working of these instruments 
when constructed of hard rubber, that a complete vacuum is pro- 
duced. By using this for a few minutes, and then puncturing, 
with Buttles's spear, from two to four ounces of blood may readily 
be drawn. The exhauster should not be used after puncturing 
but before it. All that will then be necessary will be to pass a 
sponge, attached to one of Sims's sponge-holders, over the punc- 
tured surface so as to prevent clotting in the mouths of the bleed- 
ing vessels. Local depletion by one of these methods may be 
practised with great advantage once or twice a week, the patient 
meantime being kept perfectly quiet in bed, and directed to em- 
ploy another antiphlogistic means, the application of emollient 
and sedative substances to the inflamed part. 

JEmollient and Sedative Applications. — If any parenchymatous tis- 
sue of the body be inflamed, the application of emollient and seda- 



VAGINAL INJECTIONS. 229 

tive substances in the form of simple and anodyne poultices, of 
bags of anodyne herbs, as hops or poppies, and of wet compresses, 
as employed in hydropathy, is, and has been from the earliest 
times, universally recognized as beneficial. It is upon the same 
principle that they are applied through the vagina to the cervix 
uteri by means of pledgets of cotton or lint introduced through 
the speculum, and by vaginal injections or suppositories. Other 
means," which are occasionally though much less generally em- 
ployed, are, the introduction into the vaginal canal of little bags 
filled with emollient substances, sponges impregnated with simple 
and anodyne fluids, the vapors of anaesthetic medicines, and the 
vapor of water, a plan recommended even as early as the Arabian 
school of medicine, Albucasis advising its introduction by a reed 
passed up the vagina. We are indebted to the recent work of 
Scanzoni on Diseases of Females for the explanation of the best 
method of using this important adjuvant in the treatment of 
uterine affections by injections. 

Vaginal Injections. — To be efficient they should be copious and 
long continued. There are three methods which I should recom- 
mend for their employment. Placing in a tub from one to two 
gallons of water, at as high a temperature as proves comfortable 
to the patient, she may sit over it upon a board placed across 
it, or upon a stool placed in it. The most convenient syringes 
for the purpose are the Essex and Davidson's. Both of these are 
provided with a stem about five inches long, 
which being introduced into the vagina and Fi g- 83. 

carried up so as to touch the cervix, throws, 
when the ball of the instrument is compressed 
by the disengaged hand of the patient, a 
steady stream against it. By this means a 
stream of warm water is made to pour over Davidson's syringe, 
the cervix for from twenty to thirty minutes, 
according to the amount of fatigue which the use of the instru- 
ment causes the patient. 

Another method is this : an ordinary tub or bucket, near the 
bottom of which a tube of metal has been inserted connecting 
with an India rubber or gutta-percha tube about five or six feel 
long, with a metallic stem like that of the Davidson syringe at the 
end, is placed upon an elevation, as, for example, a chair placed 




230 



CHRONIC CERVICAL METRITIS 



Fi g- 84 - upon a table, or a shelf made for 

the purpose. The vaginal stem 
being inserted, a stopcock is turned 
by the patient, and for half an 
hour a stream of water freely 
bathes the inflamed part, which, 
passing out of the vagina, pours 
into a tub over which the patient 
is sitting. This avoids all fatigue, 
and produces a much more pro- 
longed application. 

Eig. 85 represents a very inge- 
nious plan of irrigation practised 
by Scanzoni. b is a cup of lead, 
c a tube of gutta-percha, e sl nozzle by which suction is practised 
so as to fill the tube ; d is a nozzle for the vagina. After being 




Tub for vaginal irrigation. 



Fig. 85. 




zonis irrigator. 



once filled, the water pours as through a siphon. If the tube is 
rolled and dipped below the surface of the fluid, it is filled without 



SUPPOSITORIES — ALTERATIVES. 231 

the action of suction, and the siphon flow is equally well esta- 
blished. 

Lastly, the patient may take a warm hip-bath, or entire bath, 
night and morning, and use the vaginal injection while in the 
bath. This method possesses the additional advantages to be 
derived from general and hip-baths in the treatment of these cases. 

Warm water is the best, as it, is the simplest, most attainable, 
and cleanest of all the emollients which can be used for this pur- 
pose. But it may easily be medicated by addition of laudanum, 
half an ounce to the gallon, infusions of linseed, poppies, hops, 
slippery elm, hyoscyamus, conium, farina ; or by the addition of 
glycerine, one ounce to the gallon, lime-water or tar-water, both 
of which last are often very soothing to vaginitis, that may 
exist as a complication. 

Vaginal Suppositories may be made very useful if employed 
after and not instead of the injections just described, which are 
certainly of much greater efficacy. The best menstruum with 
which they can be compounded is cocoa butter, or, as recom- 
mended by Dr. Tilt in his Uterine Therapeutics, a mixture of starch, 
almond meal, and glycerine, the whole being coated with suet or 
butter of cocoa. Incorporated with these one grain of the acetate 
or sulphate of morphia, one-thirtieth to one-tenth of a grain of 
sulphate of atropia, one grain of belladonna, or three of opium 
may be placed against the os and allowed to remain all night, 
being washed away in the morning by an injection. The in- 
strument which I employ for introducing these is one of hard 
rubber, represented by Fig. 86. Should there be pain, a sedative 

Fig. 86. 




Vaginal suppository tube. 

suppository may be employed every night after the vaginal in- 
jection, but should there be no special indication for it, it is better 
not to annoy the patient with a multiplicity of applications. 

Alteratives. — These may be directly applied by means of a brush, 
by suppositories placed against the cervix, or by vaginal injections. 
Churchill's tincture of iodine, solution of persulphate of iron, or 
strong solutions of sulphate of copper, or chloride of zinc may be 



232 CHRONIC CERVICAL METRITIS. 

painted over the vaginal face of the cervix and carried up to the 
os internum. This is not done for their action upon the mucous 
lining of the canal, which we suppose not to be inflamed, but for 
the effect which they may exert on the subjacent parenchyma. 
The same drugs may be employed by injection and suppository. 

Before leaving this part of our subject it may not be out of 
place to remind the reader that vaginal injections and supposi- 
tories should not be employed under these circumstances empiri- 
cally, but with some definite object. They may serve useful 
purposes when medicated with appropriate drugs in the following 
ways : — 

1st. They may act as calmants, emollients, and detergents, 
quieting nervous irritation and soothing pain. For these indica- 
tions warm water, or any of the emollient or narcotic substances 
already mentioned, may be used. 

2d. They may exert a direct alterative influence on a tissue 
affected by granular degeneration or erosion, by coming into 
immediate contact with it. For this purpose zinc, lead, iron, 
alum, bismuth, tannin, &c, will prove useful. 

3d. They may cause absorption of lymph effused into the 
cervical parenchyma. To this end we may employ the iodide of 
potassium, chloride of sodium, sea water, water at a very high 
temperature, bromine, or iodine. 

4th. They may be employed to give tone to the pelvic tissues, 
which have been relaxed by diseased action that has passed away. 
For this purpose the astringents and cold water will prove most 
useful. In the treatment- of cervical inflammation these means 
may be brought to our aid to accomplish any of the objects 
which have been mentioned, and our choice should be governed 
by the special indication. 

In spite of all these remedial resources inflammatory engorge- 
ment will often still continue to affect the parenchyma, and it will 
become evident that other and more decided means must be re- 
sorted to. As in treating chronic parenchymatous inflammation 
elsewhere, we naturally turn most hopefully to counter-irritants. 
These are not employed for mucous inflammation, should it exist 
in conjunction with that variety which now engages us, but they 
benefit this indirectly ; for it, even although originally the cause 



COUNTER-IRRITATION. 233 

of the parenchymatous disease, is kept up by the latter, which 
reacts upon it and causes its prolongation. 

Counter- Irritation. — One of the best methods for practising 
counter-irritation upon the cervix uteri is by blistering, a means 
for which we are indebted, I believe, to Aran, of Paris. To 
blister the cervix, a large cylindrical speculum should be used 
which will take the whole part into its field. The cervix having 
been cleansed and dried by a soft sponge or dossil of cotton, a 
camel's-hair brush is dipped into vesicating collodion, which con- 
sists of ordinary collodion commonly known as liquid cuticle in 
this country, containing in suspension cantharides, and painted 
over the whole vaginal cervix, no effort being made to avoid the 
os. There are two preparations of vesicating collodion, one made 
by ether, the other by acetic acid. The second is the more power- 
ful and the less likely to affect the vagina. In a few seconds after 
it is painted on the cervix, it forms a hard insoluble covering, 
upon which two or three other coats may be at once applied. 
The whole is then exposed to the air by keeping the speculum in 
place for a few minutes, a stream of cold water projected upon it, 
to prevent any escape into the vagina, and the process is finished. 
In from eight to twelve hours the epithelial covering of the cervix 
is entirely removed by this, and a free flow of serum takes place 
as from a blister elsewhere applied. After this the patient should 
be kept perfectly quiet for several days, cleansing the vagina by 
warm injections, and as soon as the discharge shows a tendency 
to cessation the blistering should be repeated. The only objec- 
tions to this method of counter-irritation are the liability to 
vaginitis and cystitis from escape of the blistering fluid into the 
vagina and mouth of the urethra, which can readily be avoided, 
and the pain which is experienced in some cases while vesication 
is taking place. Another and still better method of destroying 



C. TltMkHH-Ca. 



<i> Fig. 87. 
-O Fig. 88. 



^ Fig. 89. 



Cauterizing irons. 

the epithelial covering of the cervix and producing serous dis- 
charge, is the application to that surface of metal wanned for 



234 



CHRONIC CERVICAL METRITIS. 



Fig. 90. 




Cervix blistered by th 
iron in four spots 



fifteen seconds in an ordinary spirit lamp. For this purpose the 
steel rods, Figs. 87, 88, and 89, used in applying the actual cau- 
tery, may be employed. One of these should be held over a 
spirit lamp for from ten to twenty seconds, and then held against 
the cervix for several seconds, a few lines always intervening be- 
tween the instrument and the os. Upon removing it a pearly white 

surface will be seen, which is created by 
death of the mucous membrane at this 
spot. The iron should again be warmed 
and applied to another spot, one such 
point being created on each side of the 
cervix, making in all three or four, as 
represented in the illustration. To this 
method there is no objection. It pro- 
duces no pain, never affects the sur- 
rounding parts, and the destruction of 
the tissue is so superficial that no indu- 
ration from cicatricial tissue results. Of 
all the means of counter-irritation for removing chronic paren- 
chymatous inflammation and causing diminution in the size of 
this part by stimulating absorption, this is the most efficient and 
least objectionable as to consequences. 

Vesication may be easily produced by still another method, 
which is very effectual and simple. By means of a solid stick of 
nitrate of silver, which is rubbed gently over the whole vaginal 
portion of the cervix, its epithelial covering is destroyed, soon 
sloughs off, and leaves a granulating surface which may be dressed 
with any of the alterative substances mentioned above. 

But sometimes so obstinate is the engorgement of the cervix, 
that other and more powerful means are required, and these pre- 
sent themselves in the actual cautery and caustic potash. Both 
methods have many objectionable features, both are liable to 
result in great induration of tissue, and a contraction of the cervi- 
cal canal after the slough which they create has passed away ; 
yet there are cases of a rebellious character, fortunately excep- 
tional ones, in which they may prove of service. The classi- 
fication of these strong caustics among counter-irritants and not 
alteratives, may be objected to by many, and yet I can see no dif- 
ference between their action on the uterus and that of issues else- 



METHOD OF APPLYING POTASSA CUM CALCE. 235 

where applied. They are unquestionably " escharotics," "altera- 
tives," and " vitality modifiers," as has been stated, but do not 
blisters and setons act in the same manner? A part, for example 
the cervix uteri, is in a state of chronic inflammation. Its blood- 
vessels are dilated, in the interspaces of its component tissues 
plastic lymph has been effused and become organized, and its 
vaso-motor nerves are in a morbid state, as if paralyzed, which 
prevents their proper functions being performed as regards circu- 
lation. A powerful counter-irritant destroys tissue to a greater 
or less extent, and produces a peculiar influence upon the vitality 
of the part, which results in a stimulation of absorption and the 
awakening of the nerve power governing these processes. 

Method of Applying Potassa cum Calce. — This preparation, con- 
sisting of two parts of lime to one of caustic potash, or two of 
the latter to one of the former, as Dr. Bennet uses it, is so far 
preferable to pure caustic potash that I shall speak of it to the 
exclusion of the more powerful escharotic. It was formerly used 
as Vienna paste, until M. Filhos prepared it in the form of a stick, 
at the same time rendering it much more powerful by combining 
two parts of quicklime with one of the caustic potash, instead of 
from thirty to fifty, as was done in the paste. A large cylindri- 
cal speculum having been introduced, and the cervix cleansed 
and completely dried, a dossil of cotton wool soaked in vinegar 
and squeezed almost dry should be forced by means of the long- 
shanked speculum forceps into the os. A larger supply, similarly 
soaked and squeezed, should then be pressed around the neck 
between it and the rim of the instrument. As acetic acid neu- 
tralizes caustic potash, this will protect all the tissues which we 
wish to avoid injuring. A stick of caustic should now be taken 
in the grasp of a caustic holder and applied to the cervix. It 
should remain in contact with its tissue for from five to ten 




Siins's caustic holder. 



seconds, then be removed and brought in contact with an adjoin- 
ing part until all the desired surface is cauterized. 



™ 



236 CHRONIC CERVICAL METRITIS. 

By the speculum syringe a stream of fluid, consisting of equal 
parts of vinegar and water, should then be repeatedly thrown 
against the cervix, a piece of cotton- wool with a string attached 
and saturated thoroughly with the same be laid against it and the 
speculum removed. After this the patient should be kept per- 
fectly quiet, and pain relieved promptly by full doses of opium, 
by mouth or rectum; for this operation is sometimes followed by 
metritis, pelvic cellulitis, or peritonitis, and I have in one case 
known tetanus occur with a fatal issue. There is not a great 
deal of danger of these results ; but it is not the less true that 
they may occur, and it is the duty of the practitioner to be fore- 
warned against the possibility. The application of this escharotic 
should always be regarded and treated as an operation, and the 
patient should distinctly understand that it is no trivial affair, to 
be lightly dealt with. 

Mode of Applying the Actual Cautery. — Yery little preparation is 
necessary for the use of this caustic. The iron being brought to 
a white heat by placing it in a fire, or still better in the flame of 
a Eussian spirit lamp, which the operator may always have at 
hand and which gives the powerful aid of a blowpipe, by its in- 
genious mechanism, is passed up through a cylindrical specu- 
lum composed of metal, horn, ivory, or wood, the last being the 
best, and pressed for a few seconds against the cervix at some dis- 
tance from the os. As soon as the tissue touched is destroyed, the 
cautery is brought in contact with another point until the desired 
amount of action is produced. A stream of water is then thrown 
against the cervix, a piece of cotton saturated with glycerine is 
introduced, the speculum withdrawn, and the patient directed to 
preserve the recumbent posture and cleanse the vagina by warm 
injections. 

The few cases to which these powerful caustics are applicable 
are great hypertrophy of the cervix, more especially hypertrophy 
with softening and puffing of the tissues, or of this and the body 
of the uterus, which have resisted all milder means; malignant 
growths and obstinate ulcerations. They should never be intro- 
duced into the cervix for fear of causing contraction of its canal, 
and because other means will answer as well without the cor- 
responding danger. Bennet, Tilt, 1 and many other excellent 

1 Tilt, Uterine Therapeutics, Am. ed., 1855, p. 92. 



TREATMENT OF CERVICAL METRITIS. 237 

authorities advise that they should be passed up the cervical 
canal, and Amussat even goes so far as to counsel the cauterization 
of the cavity of the body of the uterus, with potassa cum calce in 
cases where hemorrhage from corporeal endometritis has proved 
rebellious to ordinary means. 

The primary action of all these counter-irritants, both super- 
ficial and profound, is not the only one of which we should avail 
ourselves. The denuded surfaces, as in blistering elsewhere, 
should be acted upon by light applications of lunar caustic, tinc- 
ture of iodine, chromic acid, or any similar substances which may 
be chosen. 

This brings us to the end of what may be regarded as the most 
important subject in a work on diseases of women — the treatment 
of inflammation of the neck of the uterus. Before closing it let 
me beg the reader to note that my constant effort has been to draw 
a strict analogy between the treatment of inflammation here and 
in all other parts of the bod} r , and to make a marked distinction 
between inflammatory action affecting the two structures, mucous 
and parenchymatous. I have described inflammation of each 
separately, because by this plan greater accuracy of detail is 
attainable, but in practice they frequently exist together, and 
the practitioner will usually be called upon to combine the two 
methods of treatment which have been advised. 

Resume of Treatment of Cervical Metritis, 

1st. Rest as absolute as the health of the patient will permit, 
avoidance of sexual intercourse and muscular efforts ; removal of 
weight from fundus. 

2d. General Regimen, mild cathartics, baths, plain but nutritious 
food, avoidance of stimulants and spices, exposure to pure, fresh 
air without fatigue. 

3c?. Depletion by leeches, cups, or scarification. 

4zth. Emollient and sedative applications by vaginal injections, 
medicated and simple, or by suppositories. 

bth. Alteratives. — Applications of iodine, iron, nitrate of silver. 
&c. &c. 

6th. Counter -irritation by blisters, warm iron, actual cautery. 
potassa fusa. 



CHAPTEE XVII 



CHRONIC CORPOREAL ENDOMETRITIS. 



Like the cervix, the body of the uterus is liable to two distinct 
varieties of chronic inflammation, that affecting the mucous 
membrane which lines its cavity, and that of the parenchyma or 
tissue which makes up its walls. The first receives the name of 
corporeal endometritis, in contra-distinction to cervical endome- 
tritis ; the second that of corporeal metritis, which distinguishes 
it from the cervical form of the same disease. 

Synonymes. — This disease has been described under the names 



of endometritis, uterine catarrh, uterine 



Fig. 92. 



leucorrhoea, and internal metritis. The 
precise seat of the affection is pointed out 
by the lines of dots in Fig. 92. 

Frequency. — Few points in uterine pa- 
thology have created more discussion of 
late years than this. Some excellent 
authorities, following the lead of Dr. 
Henry Bennet, regard it as of rare occur- 
rence, while a large majority consider it 
quite common. "Internal metritis," 1 says 
Aran, "is more frequent, nevertheless, in 
spite of all that has been said to the con- 
trary, in the cavity of the body than in 
the cavity of the neck of the womb ;" and 
this opinion is concurred in by Dr. West 
and others. To show how unsettled this 
point is in the present state of pathology, 
let me contrast with this statement that of Prof. Byford, 2 of Chi- 
cago, whose excellent work on Medical and Surgical Treatment of 
Women has recently appeared: "Inflammation limited to the 




The lines of dots show the site 
of corporeal endometritis. 



1 Mai. de l'Uterus, p. 408. 



2 Op. cit., p. 182. 



NORMAL ANATOMY. 239 

cavity of the body of the "uterus is not common, but I am quite 
sure that I have met with at least two instances." While Dr. 
Byford's experience furnishes him but two instances, Dr. Tilt 
gives the statistics of fifty cases of which he has kept notes. 

The more industriously the student of Gynecology interrogates 
the literature of this subject, the more unsettled are his conclu- 
sions likely to be, and unfortunately his own investigation, how- 
ever carefully conducted, will often fail to enlighten him in the 
individual cases with which he meets, for the differential diagno- 
sis between cervical and corporeal endometritis is often very 
difficult. My own opinions upon this important point I shall 
state freely, unbiassed by those of authors for whom I entertain 
the highest respect, but whose conclusions conflict with what I 
have carefully observed at the bedside. The most frequent 
locality of uterine inflammation is that portion of the uterus be- 
low a line running across it through the os internum. That por- 
tion of the organ above this line, however, is much more com- 
monly affected by inflammatory disease than is stated by Dr. 
Bennet. During the past eighteen months I have met, in private 
practice alone, nine well-marked and unquestionable cases, and 
with several more in which I could not satisfy myself as to the 
exact limit of the disease. The lining membrane of body and 
cervix may be simultaneously affected, but this is the exception 
and not the rule ; generally we find one or other portion of the 
organ the seat of disease. In making this last assertion I am 
fully aware of its importance, and of the fact that it will be dis- 
sented from by a great many. But feeling convinced as I do that 
upon its non-recognition depends a certain amount of the obscurity 
attending the differentiation of metritis of the neck and body, I 
wish to fix the attention of the reader upon it. 

Normal Anatomy. — If the mucous membrane of the uterus be 
examined by a lens, it will be seen to be studded with minute 
openings somewhat similar to the mouths of the glands of Lieber- 
kuhn in the intestines. These are the mouths of Ions:, curling 
follicles which project by their closed extremities downwards 
towards the parenchyma of the organ. They are lined by delicate 
epithelium, and are supposed to secrete mucus in the non -pregnant 
state. During pregnancy they become excessively active, and 
undergo great hypertrophy. 



240 CHRONIC CORPOREAL ENDOMETRITIS. 

Pathology. — Corporeal endometritis is, like the same affection 
in the cervix, a glandular disease. The utricular follicles are the 
seat of the disorder, and it is to the exaggeration of their secretory 
functions that is due the uterine leucorrhcea, which constitutes 
one of its prominent symptoms. 

Causes. — These may be enumerated as follows : — 

Exposure during menstruation ; 

Sudden checking of the menstrual flow ; 

Obstruction to escape of menstrual blood ; 

Abortion and parturition ; 

Inflammation of the cervix ; 

Acute corporeal metritis or endometritis ; 

Sexual intercourse ; 

Injury from sounds, intra-uterine pessaries, and injuries re- 
sulting from attempts to produce abortion ; 

Certain hasmic conditions, as those accompanying phthisis 
and exanthematous diseases ; 

Tumors in the uterine cavity or walls. 
It is quite clear how either of the first two causes, in checking 
hemorrhage from the congested mucous lining of the uterine body. 
may at once induce the first stage of this disease. They generally 
result in the acute variety, which may rapidly pass off, but which 
sometimes ends in the chronic form. 

Obstruction to escape of menstrual blood is a very fruitful source 
of the affection. The menstrual blood, if it pours at once into the 
vagina, remains fluid from admixture of an acid mucus secreted 
by the lining membrane of that canal ; but if it is imprisoned in 
the uterine cavity, where only an- alkaline mucus exists, it very 
soon becomes clotted. These clots are, of course, too large to 
pass through a cervix of normal dimensions, much more so to 
escape from one unnaturally constricted. Their presence in the 
uterine cavity, together with that of blood which they imprison, 
in time excites contraction, by which they are expelled. But 
this repeated dilatation and contraction cannot last long without 
exciting inflammation in the mucous lining either of the body, 
the cervix, or of both. Such an obstruction may have as its cause 
a small polypus, which acts as a ball valve at the os internum, 
congenital or acquired narrowness of the cervical canal, uterine 
flexion, or swelling of the cervical lining from congestion. 



PATHOLOGY. 241 

The parturient process is a very frequent source of the disease, 
especially where the unripe placenta is prematurely separated 
from its uterine connection. Where, as in a prolonged labor, the 
early evacuation of the liquor amnii leaves the irregular outline 
of the body of the child pressing against the uterine investment 
for many hours, such a sequel is not astonishing. 

Of cervical inflammation Dr. Bennet 1 thus expresses himself: 
"It" (i.e., corporeal endometritis) "appears, however, to be gene- 
rally met with in practice as the result of the lengthened existence 
of inflammatory disease of the cervix and its cavities. The in- 
flammation gradually progresses along the cavity of the cervix 
until it reaches the os internum, and passes into the uterus." I 
have already stated my dissent from this view, although, at the 
same time, I admit that it sometimes holds true. 

Acute metritis may, instead of subsiding entirely, very naturally 
run into this disease. 

Sexual intercourse as a causative influence is frequently observed 
soon after marriage, the first connubial approaches exciting it with 
greater or less intensity. Dr. Tilt 2 remarks, with reference to it: 
"It is useless to disguise the fact, connection has a downright 
poisonous influence on the generative organs of some women." I 
cannot believe that the Almighty has ordained a function as 
essential to the perpetuation of our species which has a down- 
right poisonous influence on the generative organs of a healthy 
woman. And yet, to a certain extent, the statement is correct, for 
upon a woman who has enfeebled her system by habits of indolence 
and luxury, pressed her uterus entirely out of its normal place, 
and perhaps goes to the nuptial bed with some lurking uterine 
disorder, the result of imprudence at menstrual epochs, sexual 
intercourse has indeed such an influence. The taking of food 
into the stomach exerts no poisonous influence on the digestive 
system, but the taking of food by a dyspeptic who has abused and 
injured that organ, does so. 

Injuries from sounds, &c, act so evidently in exciting inflam- 
mation as to need no explanation. 

Certain conditions of the blood sometimes produce acute corpo- 
real endometritis, which, as already stated, may pass into that 

1 Op. cit., p. 75. * Op. cit., p. 234. 

16 



242 CHRONIC CORPOREAL ENDOMETRITIS. 

form under consideration. As a complication of the exanthema- 
tous diseases endometritis is well known, and its occurrence with 
phthisis has been noted by Dr. Gardner in the American edition 
of Scanzoni. Every practitioner must have noticed it in connec- 
tion with that affection. 

Tumors in the cavity or walls of the uterus very generally 
produce this disease in consequence of the congestion of the 
mucous membrane which they cause. 

Symptoms. — The symptomatology of corporeal endometritis 
constitutes one of the most unsatisfactory and obscure subjects 
in the entire field of Gynecology. At times its symptoms are so 
slight and at others so masked and obscure that the disease often 
runs a lengthy course without exciting the suspicions of either 
physician or patient. Its effects upon the constitution also differ 
most unaccountably in different cases. Sometimes the disease will 
continue for ten, fifteen, or twenty years, producing profuse leucor- 
rhcea, menstrual disorders, and nervous derangement, and yet 
result in no annoyances so grave as to cause the patient to seek 
medical aid. At others it passes rapidly into disease of the super- 
ficial parenchyma, which induces displacement and causes great 
pain on locomotion, sexual intercourse, and the passage of feces 
through the rectum, or results in an ichorous discharge, which 
creates the most annoying symptoms of vaginitis, cystitis, or 
pruritus vulvas. The chief symptoms which usually present 
themselves in a case of uncomplicated mucous metritis of the 
uterine body are — 

Leucorrhoea'; 

Menstrual disorders ; 

Pain in the back, groins, and hypogastrium ; 

Nervous disorders ; 

Tympanitis ; 

Symptoms of pregnancy ; 

Sterility. 
Profuse leucorrhoea of glairy character is one of the chief signs 
of the affection. This, when very tenacious and thick, is the pro- 
duct of the Nabothian glands, but the lining membrane of the 
uterus likewise secretes a similar fluid, differing from it chiefly in 
possessing the qualities mentioned, in a very much less marked 
degree. But uterine leucorrhoea differs from cervical in other 



SYMPTOMS- 243 



particular, ; it j, „ft„ mo „ „ tes ; 
P-reS— JETER? "SlT? T '? '^ 

Menstrual disorders are rarely absent Th* M*^ 

.»« *» rr , „» h „ iv i*Xau srr 
ss^aa- " b - -*■ - -- • — 



1 Op. cit., p. 



76. 



244 CHRONIC CORPOREAL ENDOMETRITIS. 

ences governing peristalsis and giving tone to the intestinal mus- 
cular tissue, which proceeds to such an extent as to result in 
accumulation of gases in that canal. In the same way it may 
induce constipation, which is often one of its most obstinate accom- 
paniments. 

Symptoms of pregnancy often exist as symptomatic of the dis- 
ease, and sometimes mislead the physician. Nausea and vomiting 
are by no means invariably present, but are valuable as positive 
signs. They appear to result from this disease as they do from 
occupation of the uterine cavity by the product of conception. 
Sometimes, in addition to these, there are darkening of the areolae 
of the breasts, and enlargement and' sensitiveness of the mammary 
glands. When to these are added abdominal enlargement, from 
tympanitis and irregularity of menstruation, it will be perceived 
how easily an error might creep into the diagnosis. 

Sterility is so commonly a result of endometritis that it should 
be considered as one of its signs. Yery often it has been the only 
symptom that has led to an investigation of the state of the 
uterus which has determined the existence of the disease. The 
affection does not, however, preclude the possibility of conception ; 
it only diminishes the probability. 

Physical Signs. — The physical signs are neither numerous nor 
reliable, and those of real value only will be mentioned. The 
uterine probe passed into the cavity will often show the length 
of the uterus to be greater than it would be in health. The 
mucous lining being gently struck by the probe, pain will be 
at once complained of, and a few drops of blood with mucus 
will follow its withdrawal from the cavity. Upon conjoined 
manipulation, two fingers being placed in the fornix vaginae, or 
one behind the uterus in the rectum, and the fingers of the other 
hand made to depress the anterior wall of the abdomen, sensitive- 
ness will be found in the body of the organ. The recognition of 
the absence of cervical disease, while at the same time there are 
profuse uterine leucorrhoea and the other symptoms recorded, will 
lead us strongly to suspect it. Lastly, dilatation of the os inter- 
num, with or without that of the external os, may be taken as a 
corroborative sign. 

Course, Duration, and Termination. — It is very doubtful whether 
this affection, like that of the cervix, is susceptible of spontaneous 



PATHOLOGY — PROGNOSIS. 245 

cure, or eradication by constitutional means alone. It may 
be palliated by alterative and tonic influences, diminished in 
severity and relieved of complications by constitutional means, 
but I have never seen a case thus cured. If not cured, the tend- 
ency of the mucous inflammation is to excite parenchymatous 
and thus to induce uterine displacements with their attendant evils. 
The duration of the disease is unlimited, twenty and thirty years 
often elapsing without its removal. It is astonishing to see how 
long the affection will remain confined, in some cases, entirely to 
the mucous membrane and not affect the parenchyma to any 
appreciable degree. 

Pathology. — I have had three opportunities for examining post- 
mortem into the pathology of this disease, uncomplicated by 
parenchymatous or other attendant disorder. Two of these cases 
were presented to the Obstetrical Society of this city. In these 
instances the condition described by Scanzoni was most evident. 
The uterine cavity was found considerably enlarged, its walls 
diminished in thickness, and in one instance they were pronounced 
by Dr. J. B/Keynolds, after microscopical examination, to be in 
a state of fatty degeneration. The uterine neck was in every case 
found healthy both as to parenchymatous and mucous structure 
and the enlarged body displaced by anterior or posterior flexure. 
The mucous lining of the body was in two cases quite smooth 
and to a great extent deprived of epithelium, while in the third 
it was roughened, and presented points where the enlarged blood- 
vessels created a number of reddish spots. But enlargement of 
the uterine cavity is not always present; it marks chronic cases, 
and would not be recognized in those of recent origin. It is highly 
probable, too, that in cases of recent origin the pathological ap- 
pearances which have been here described would not be found to 
exist, but in place of them a thickened, congested, and florid 
appearance would present itself. 

Prognosis. — The prognosis of chronic inflammation of the ute- 
rine body is always grave with reference to cure. Even if the case 
is not of very serious character, and has lasted only a short time, 
the possibility of rapid recovery is doubtful, while, if it has con 
tinued for a number of years it will often prove incurable. Scan- 
zoni 1 says, with a candor which does him honor : "As for ourselves 

1 Scanzoni, Diseases of Females, Am. ed., p. 202. 



246 CHRONIC CORPOREAL ENDOMETRITIS. 

we do not remember a single case where we have been able to 
cnre an abundant uterine leucorrhoea of several years' standing." 
In most cases a certain amount of amelioration may be effected 
even when they are of long standing ; in a certain number treated 
early, cure may unquestionably be accomplished ; while in a great 
many nothing whatever, either in the way of cure or of relief, can 
be obtained, and the patient, after passing from physician to phy- 
sician, settles down into a careful mode of life, resolved to cease 
treatment and bear as best she may an evil which she has learned 
to regard as incurable. 

The symptoms of a hopeful and desperate case of corporeal 
endometritis may be thus contrasted : — 

Prognosis is Favoeable when i Prognosis is Unfavorable when 

The case is of recent standing ; The case is of long standing ; 

The discharge is mucus or blood ; j The discharge is purulent ; 

Dysroenorrhceal shreds are not cast off; Dysmenorrhoeal shreds are cast off; 

Patient naturally of strong constitution ; ' Patient naturally of feeble constitution ; 

Parenchyma is not affected ; j Parenchyma is affected ; 

No displacement exists ; Displacement exists ; 

Dimensions of cavity are not increased ; ; Dimensions of cavity are increased ; 

Discharge does not produce vaginitis ; j Discharge produces vaginitis ; 

Nervous system is not involved ; ■ I Nervous system is involved ; 

Patient near menopause. | Patient not near menopause. 

Complications. — The complications of the disease are cystitis, 
vaginitis, rectitis, ovaritis, corporeal metritis, cellulitis, and pelvic 
peritonitis. 

Treatment. — Special attention should be given to sustaining 
and improving the general health of the patient, which will always 
show a marked tendency to depreciation. Good diet, fresh air, 
systematic exercise, and avoidance of all circumstances calculated 
to depress the spirits or harass the mind should be recommended. 
If practicable, change of air and scene should be brought to our 
aid, and the patient sent occasionally to some suitable watering- 
place or country resort. The healthy condition of the nervous 
and sanguineous systems will be fostered by these measures, 
and should medicinal tonics be required, iron, the mineral acids, 
quinine, the bromide of potassium, or nux vomica may be admi- 
nistered. All condiments, as spices, and aromatics, should be 
avoided, and the patient should be guarded against habits of indo- 
lence and luxury which tend to exhaust the nervous strength. 



APPLICATION OF ALTEEATIVES. 247 

The uterus should be placed at rest by removal of pressure 
upon the fundus by clothing, cessation of marital intercourse, and 
avoidance of violent and intemperate exercise. 

The part affected being removed from the vagina on the one 
hand, and the pelvic and abdominal walls on the other, little 
advantage results from the emollient applications and depletory 
means which prove so useful where the cervix is diseased. Our 
chief hope of affording relief must rest upon the general means 
just mentioned, and upon the direct application to the diseased 
surface of alterative remedies. 

Medicated Tents. — I know of no plan which promises better 
results than the use of sponge tents, medicated as advised on page 
221 when they can be borne. These are passed completely up to 
the fundus uteri and allowed to remain for twenty four hours, 
when, by a thread attached to them, the patient may remove 
them without difficulty. Teuts medicated with iron, iodine, zinc, 
potassium, or copper, may be employed once a week with great 
advantage. Not only does the medicinal substance come fully in 
contact with the uterine walls, but the pressure exerted by the 
expanding sponge likewise proves beneficial. 

Application of Alteratives. — Recamier was the first who had the 
boldness to cauterize the cavity of the uterus, which he did by 
means of nitrate of silver in an ordinary porte-caustique. The 
practice thus . introduced was continued and spread abroad by 
Robert, Richet, Trousseau, Maisonneuve, and others, and to-day 
is esteemed one of our most reliable methods for combating this 
rebellious affection. There are four methods by which it may be 
practised : 1st, by the use of solutions painted over the surface ; 
2d, by ointments left to melt in utero ; 3d, by injections of fluid 
into the cavity of the body ; 4th, by solid caustics. In commenc- 
ing treatment the practitioner should see that the cervical canal 
is well opened in order to admit the free escape of the fluid from 
the cavity above and the application of substances through it 
from below. This perviousness, should it not exist, should bo 
secured by the use of tents and the local treatment be proceeded 
with. If the uterus is found sensitive to vaginal and rectal touch 
the patient should remain in bed for some days before the first 
application is made, the bowels be kept active by mild saline pur- 
gatives, and warm baths or hip-baths with copious vaginal injee- 



248 CHRONIC CORPOREAL ENDOMETRITIS. 

tions employed. If the operator uses the ordinary long, cylindrical 
speculum, in the majority of cases he will fail to accomplish the 
end in view, reaching the fundus uteri, for through such an 
instrument, it is always difficult and dangerous to penetrate so 
high into the cavity. If, however, he uses the Sims speculum, 
or one of its modifications, or the short, telescopic, cylindrical 
instrument, he will succeed without effort or delay. The instru- 
ment being introduced and the cervix cleansed by the speculum 
syringe, the operator very gently passes to the fundus Sims's 
uterine probe and learns the exact course of the canal. Then, 
placing the flat dressing -probe by the side of this, he gives it the 
exact curve he has ascertained to be that of the uterine canal, and 
wrapping it with a thin film of cotton passes it to the fundus. 
This removes a good deal of mucus from the cavity which would 
otherwise have neutralized the caustic introduced. Removing 
the cotton from the probe, he wraps another piece around it, or, 
as is better, uses another probe already wrapped, and, dipping this 
into the fluid caustic which he has determined to use, he passes it 
directly to the fundus and keeps it still for from thirty seconds to a 
minute. This should not be repeated, for the astringent action of 
the caustic makes it difficult to do so, and if properly done the 
first time a repetition will be unnecessary. After this the patient 
should go to bed and remain perfectly quiet for three or four days, 
if a strong caustic has been used, for one or two days if a mild 
one has been employed. 

The caustics which may be thus employed are : — ■ 

Solution of chromic acid £j to 3jj water ; 
Solution of nitrate of silver 9j or £ss to ^j water ; 
Churchill's tincture of iodine Jss to £j glycerine ; 
Saturated solution of sulphate of zinc ; 
Saturated solution of sulphate of copper ; 
U. S. D. solution persulphate or perchloride of iron : 
Solution of chloride of zinc ^j to gj water ; 
U. S. D. muriate tincture of iron ^ij to 3J water. 

It is evident that by the admixture of water, or glycerine, which 
is better, these may be weakened to any extent desired. Should 
the saturated solution of strong caustics, like chromic acid, be 
employed, let the practitioner be sure that there is no excitement 
about the uterus at the time the application is made, that not one 



SOLID CAUSTIC TO CAVITY OF UTERUS. 249 

superfluous drop be allowed to saturate the cotton, and that the 
patient be perfectly quiet after the application. No one, unless 
familiar with the practice, should resort, at first, to strong caustics, 
but make use of one of the milder ones until he acquires the re- 
quisite skill. This method of employing fluid caustics is that in- 
troduced into the Woman's Hospital in this city, by Dr. Sims, and 
surpasses any other with which I am familiar. 

Use of Ointments. — The use of ointments is proceeded with in 
much the same manner, except that a different instrument is, of 
course, necessary for their introduction. That which answers the 
purpose best is the invention of Dr. F. D. Lente. It consists of 
a syringe with a silver tube attached as represented in Fig. 93. 
The ointment to be employed is put into the syringe by a spatula, 



Lente's ointment syringe. 

and the tube being introduced into the uterine cavity the piston 
is pushed forward and the ointment is forced out. The following 
are the ointments which are generally thus employed, though 
any others — as lead, bismuth, calomel, iodine, &c. — might be sub- 
stituted : — 

R. — Argenti nitratis, gij ; 

Bell ado nnae ext., 3J ; 

Ungt. spermaceti, ^ij. — M. 
R. — Plumbi acet., 31J ; 

Morph. sulphat., gr. iv ; 

Butyr. cacao, ^ss ; 

01. olivae, q. s. — M. 

The Application of Solid Caustic to the Cavity of the Uterus. — The 
only caustic which is ever thus employed is the nitrate of silver. 
for although one author has advised a similar use of potassa cum 
calce, no one of whom I have heard has followed his counsel. The 
use even of lunar caustic gives such great pain and causes such 
grave constitutional symptoms that it never can become a popular 
therapeutical resource. It is, however, of great value in obstinate 



250 CHRONIC CORPOREAL ENDOMETRITIS. 

cases and should always be held in reserve. Sometimes the se- 
verest uterine colic is produced by it, with nausea, vomiting, and 
great prostration. So violent have these symptoms been in some 
cases that I have been forced to use the hypodermic syringe freely 
for their relief, and now often employ it before resorting to the 
method. By Lente's probe the cauterization is accomplished in 
an easy and elegant manner not attainable by any other method. 
The nitrate being fused in the little instrument of platinum, repre- 
sented on page 220, and the tip of the probe coated, the direction 
of the uterine cavity having been previously ascertained by Sims' s 
probe, it is properly curved and passed in. By it every part of 
the uterine mucous membrane is thoroughly touched, the probe 
being kept within the cavity until its envelope has melted off. 
This application should be always treated as an operation. The 
patient should be warned of the pain which she will be likely to 
suffer and the practitioner remain with her or visit her within an 
hour after the application has been made, prepared to give relief 
by the hypodermic syringe. 

Injections into the Uterine Cavity. — There can be no question of 
the fact that by this means endometritis may be cured, nor of 
the additional fact that it may be used a great many times with- 
out injurious results. But it is ordinarily attended by great 
danger, and no one, not even he who has the largest experience, 
can tell when a fatal issue may ensue from it. The fluid 
thrown into the uterus is liable to pass through the Fallopian 
tubes into the peritoneal cavity and produce the most alarming 
collapse, or peritonitis and death. The literature of the subject 
contains a number of cases in which death has thus resulted. It 
has been found, however, that if the cervical canal be dilated by 
tents so as to allow of the escape of fluids from the cavity of the 
body, these dangers disappear to a great degree, and by anticipat- 
ing the injections by such means we may cautiously avail our- 
selves of them. The substances which may be thus used are 
persulphate of iron, tincture of iodine, weak solutions of nitrate 
of silver, sulphate of zinc, sulphate of copper, &c. The method 
for employing uterine injections is very simple. A long -necked 
syringe, charged with the substance to be used, should be passed 
into the cervix through the os internum and the fluid very slowly 
and gently expelled; or a small syringe may be fitted by its 



INJECTIONS INTO THE UTEKINE CAVITY. 251 

nozzle into a gum-elastic catheter, the extremity of which is 
passed into the uterine cavity and the fluid slowly discharged. 

The use of the curette in the treatment of corporeal endome- 
tritis is generally mentioned in works upon this subject, hut the 
curette is not really used for this disease. It is employed to 
remove one of its results which produces metrorrhagia, for the 
checking of which it is most commonly resorted to. I allude to 
papillary growths in the uterus. 



CHAPTER XVIII. 



CHBONIC CORPOREAL METRITIS. 



Fig. 94. 



Definition and Synonymes. — This term is applied to inflamma- 
tion, of the parenchymatous structure making up the walls of 
the uterine, body. It has been described under the names of 
metritis, parenchymatous metritis, inflam- 
matory engorgement and hypertrophy of 
the uterus. 

Frequency. — This part of the uterus, as 
already stated, is not so frequently affected 
by inflammation as the same tissue of the 
cervix. Still it is by no means uncom- 
monly diseased. A large number of cases 
of incurable uterine disorders occurring 
as a remote result of parturition are 
really of this nature, and the displace- 
ments, rebellious leucorrhcea, and other 
concomitant evils which characterize them 
are merely symptoms of the parenchyma- 
(j I tous affection. An important fact con- 

The dots show the site of nected witn this state is one to which atten- 
corporeai metritis. tion has been drawn by Dr. E. E. Peaslee. 

It is that where pathological hypertrophy of 
the areolar tissue exists as the chief element of metritis, temporary 
or transient attacks of active congestion frequently occur and 
excite from time to time acute symptoms. These pass awav, 
leaving the basis of the affection in its original state, soon to 
return with all the symptoms of relapse. And thus a series of 
short but severe exacerbations go on developing themselves in 
the ordinary course of an attack of the disorder. 




SYMPTOMS. 253 

• Causes. — Parturition or abortion ; 
Sub-involution ; 
Cervical metritis ; 
Displacements; 
Corporeal endometritis. 

In the vast majority of cases the disease results from some dis- 
order occurring subsequent to pregnancy. The puerperal state 
may be said to be the great predisposing cause of the condition, 
which is met with very rarely without its having existed. It 
may be that upon the exuberant state of the uterine areolar tissue 
produced by pregnancy, a low grade of metritis has been en- 
grafted, or that an arrest in the physiological absorption of the 
uterus has occurred. In either case the affection which we are 
considering is likely to be the result. It is sometimes, though not 
often, the result of inflammation of the mucous lining, and hence 
anything which directly excites endometritis may possibly pro- 
duce it indirectly. Cervical metritis may likewise pass upwards 
and affect by contiguity of structure the parencyhma of the body. 
Corporeal metritis is generally the cause of uterine displacements, 
but it may in certain rare cases result from a displacement which, 
interfering with uterine circulation and causing a congestion of its 
structures, may produce a low grade of chronic inflammation and 
hypertrophy of the areolar tissue. Although all these influences 
must be admitted as occasionally productive of metritis, the fre- 
quency of parturition as the great moving cause must be carefully 
insisted upon. 

Symptoms. — The symptoms generally resemble very closely 
those of corporeal endometritis. The following are especially in- 
dicative of the parenchymatous affection. 

A dull, heavy, dragging pain through the pelvis, much in- 
creased by locomotion; 

Pain on defecation and coition ; 

Pain of severe character beginning several days before men- 
struation, and lasting during that process ; 

Pain in the mammae, before and during menstruation ; 

Darkening of the areolae of the breasts ; 

Nausea and vomiting ; 

Great nervous disturbance ; 

Pressure on the rectum with tenesmus and haemorrhoids; 

Pressure on the bladder with vesical tenesmus. 



254 CHRONIC CORPOREAL METRITIS. 

I would not convey the impression that these symptoms are 
distinct from those of corporeal endometritis, and that none of 
them occur with it. As already stated, the symptoms of the two 
affections are interwoven so frequently, and to such a degree, 
that they cannot be completely separated. Where, however, the 
mucous affection has lasted long, and the parenchyma becomes 
diseased, the symptoms just detailed superadd themselves to those 
before existing. 

Physical Signs. — If two fingers be carried into the vagina and 
placed in front of the cervix so as to lift the bladder and press 
against the uterus, while the tips of the fingers of the other hand 
be made to depress the abdominal walls, the body of the uterus 
will, unless the woman be very fat, be distinctly felt, should the 
organ be anteflexed. Should it not be detected, let the two fingers 
in the vagina be now carried behind the cervix into the fornix 
vaginae, and the effort repeated ; if the uterus be retroflexed or 
retroverted, or even in its normal place, it will be detected at 
once. By these means we may not only learn the size and shape 
of the organ, but its degree of sensitiveness. This may likewise 
be accomplished to a certain extent by rectal touch. The uterine 
probe should then be introduced, the cavity measured, and the 
sensitiveness of the walls carefully ascertained. 

Course, Duration, and Termination. — Unlike an inflammation 
in other parenchymatous structures, inflammation in that of the 
uterus does not tend to suppuration. Usually the organ enlarges, 
becomes displaced, and remains in this condition until the meno- 
pause ; or absorption of the superfluous material takes place, and 
it returns to its natural size or becomes atrophied. 

Pathology. — Most pathologists agree in the assertion that the 
affection consists in congestion of the parenchyma, which is fol- 
lowed by an effusion of liquor sanguinis into its tissue. Du- 
parcque 1 maintains that the muscular fibres are separated by a 
fibro-albuminous material, which may be forced out by pressure 
or scratching, and that it is this material which, subsequently 
contracting, strangulates the vessels that it surrounds, and pro- 
duces atrophy. Scanzoni 2 declares that there is an "hypertrophy 
of the cellular tissue," which results from organization of the 

1 Mai. de la Matrice, p. 244. 2 Qp. cit., p. 161. 



DIFFEKENTIATION. 



255 



material effused ; and this view is adopted by Klob and others 
of the German school. 

Differentiation. — The diseases with which it may be confounded 
are: — 

Cervical metritis ; 

Pregnancy ; 

Neoplasms ; 

Perimetritis. 
From all a most careful differentiation should be made ; for if 
in error, the practitioner would not only surely fail in giving 
relief, but might do great injury. For example, an examina- 
tion by the probe might produce abortion, or so aggravate peri- 
uterine inflammation as to cause serious and alarming conse- 
quences. The introduction of the probe or sound should, for this 
reason, be practised with great caution, and only when good 
reason exists for supposing pregnancy and perimetritis absent. 

For distinguishing this disease from cervical metritis the fol- 
lowing means will be those upon which we must rely. We will 
suppose that we are dealing with a complicated case in which 
both tissues, mucous and parenchymatous, are affected, and not 
with one of those in which the parenchyma alone is diseased. 



Corporeal Metritis and Endometritis. Cervical Metritis and Endometritis. 



Glairy, purulent, and bloody leueor- 
rhoea; 

Tympanites, often marked ; 

Uterine tenesmus ; 

Nausea and vomiting ; 

Dysmenorrhea severe, days before flow ; 

Nervous symptoms grave, despondency 
and sleeplessness present ; 

Tendency to exfoliation ; 

Mammae painful at epochs ; 

Areolae darkened ; 

Size of cavity often increased ; 

Probe gives pain and a few drops of 
blood ; 

Conjoined manipulation shows sensitive- 
ness of body. 



Glairy and very tenacious leucorrhcea, 
perhaps streaked with blood ; 

None ; 

None ; 

Not common ; 

Not severe ; 

Not so grave, no sleeplessness nor great 
despondency ; 

None ; 

Not so ; 

Not so ; 

Not so ; 

Does not ; 

Does not ; 



Between commencing corporeal metritis, which is very apt to 
become aggravated under the influences of matrimony, and preg- 
nancy, there is a chance of error in diagnosis; for in both there 



256 CHRONIC COEPOEEAL METRITIS. 

are enlargement of the breasts, darkening of the areolae, enlarge- 
ment of the uterus, derangement of the nervous system, and 
nausea and vomiting. In the one, however, menstruation does 
not cease, there is no kiesteine in the urine, there is great sensi- 
tiveness of the body of the uterus, and an abundant leucorrhcea. 
Dr. Tilt has drawn especial attention to this important fact : 
11 When most of the symptoms of early pregnancy are present," 
says he, " without menstruation being suspended, in compara- 
tively young women, internal metritis may be suspected." 

ISTeoplasms or fibrous growths in the uterine walls will some- 
times, from the peculiar symmetry of their development, com- 
pletely mislead us, giving uterine enlargement, leucorrhcea of 
bloody character, &c. &c. I have now in my possession a uterus 
in the anterior wall of which a fibrous tumor, equal in size to a 
goose's egg, gives all the appearance of engorgement of uterine 
tissue with anteflexion and endometritis. The only way in which 
a diagnosis could be made under such circumstances would be by 
the proper use of the uterine sound, and carefully studying the 
individual case by means of this and conjoined manipulation. 

Perimetritis, unless accompanied by endometritis, is unattended 
by leucorrhcea, and by it the uterus is rendered immovable. The 
uterine probe, if employed in such a case, should be used with 
great caution, and would show no sensitiveness of the uterine 
walls and no increase in the size of the cavity of the uterus. 

Prognosis. — The prognosis is unfavorable with regard to cure, 
though highly favorable with reference to danger to life. Should 
the patient be approaching the menopause, hope may be held out 
that after the functions of the uterus cease, atrophy may occur 
and relief be obtained. But one cannot be sure even of this, for 
the monthly discharge may give place to metrorrhagia, or all 
the symptoms of metritis may continue in spite of the menstrual 
cessation. 

Treatment. — Xo one, in the present state of uterine pathology 
and therapeutics, can write very positively upon this subject for 
it really constitutes one of the opprobria of Gynecology. The 
rules laid down for the treatment of parenchymatous disease be- 
low the os internum will disappoint us here. \Ve cannot from 
the same means expect the same flattering results. The thera- 



TREATMENT — REST. 257 

peutic resources which were recommended for cervical inflamma- 
tion were these : — 

Eest ; 

General regimen ; 

Depletion ; 

Emollients; 

Alteratives ; 

Counter-irritants. 
Unfortunately in corporeal inflammation they often all fail to 
accomplish a good result. Nevertheless, since some cases are 
relieved by them, and a smaller number cured, it is our duty to 
essay them cautiously — so cautiously as to feel assured that if we 
accomplish no good, at least we shall do no evil. 

Rest. — It is not only useless but injurious, in a disease which 
will probably last for many months and perhaps years, to confine 
a patient to bed, for her general health will almost surely suffer if 
such a course be persisted in. She should be required to lie 
down for the greater part of the day while treatment is being in- 
stituted, and to remain quiet during menstruation, and for some 
days after applications have been made to the diseased part, but 
every day she should go, unless deterred by some such cause, 
into the open air, and a limited amount of exercise should be 
inculcated as a means of keeping up the general health. 

The uterus should be placed at rest as much as possible. Its na- 
tural tendency under these circumstances is to fall from its posi- 
tion, consequently all pressure should be removed from its fundus 
by the use of skirt supporters and a well-fitting abdominal band- 
age. These bandages are very unpopular with many practitioners, 
who believe that they absolutely do harm. I believe otherwise, 
and regard them as great adjuvants, not in keeping up the uterus, 
but in supporting the superimposed viscera which, pressed down- 
wards by tight clothing, and badly supported on account of the 
relaxation of the abdominal walls, fall directly upon the fundus. 
There is a great variety of abdominal supporters. I have no 
favorite, for one will accomplish the end in a woman of a certain 
figure which would be inappropriate for another. Some very 
simple and efficient supporters, which will answer the purpose in 
all but emaciated patients, are presented in the accompanying 
diagrams : — 
17 



258 CHRONIC CORPOREAL METRITIS. 

Fig. 95. Fig. 96. 




Abdominal supporter of jean or silk. 



Abdominal supporter in which the pad covers 
the hypogastrium. 



Two additional patterns are depicted in Chapter IX., upon 
prolapse of the vagina. That one should be selected which abso- 
lutely accomplishes the end in view, namely, sustaining the vis- 
cera and supplementing the weakened muscles of the abdomen. 
In addition to these means of procuring rest for the uterus, the 
patient should, as far as possible, lead a life of celibacy. 

After displacement has occurred, and even before it has done 
so, great benefit may often be obtained from support rendered by 
means of a light and well-fitting pessary, the elastic ring of Tie- 
mann & Co., the accommodating lever of Scattergood, or the sup- 
porter of Cutter, for example. In some cases the benefit derived 
from these instruments will be the chief, perhaps the only relief 
which we can bestow, and even where we cannot cure the disease 
we may by their use render life much more agreeable by the alle- 
viation of discomfort. 

General Regimen. — The diet should be plain and unstimulating, 
but at the same time nutritious, and in every way calculated to 
maintain the normal state of the blood. Should spanasmia exist, 
ferruginous tonics, alone or combined with vegetable tonics, 
should be administered. The bowels should be kept in a per- 
fectly healthy state, and the skin active. Specific remedies have 
been, and are still, employed by some practitioners for stimulating 
absorption of the effused plasma. Foremost amongst these are 
the iodide or bromide of potassium, iodine and preparations of 
mercury. Their efficacy is doubtful, although many excellent 
physicians rely upon them with confidence. 



DEPLETION — EMOLLIENTS. 259 

No other general means compare in results with a change of 
abode and corresponding change of air, habits, and associations. 
A removal, for example, to the sea-side, where bathing can be 
enjoyed, a sea voyage, or a residence at an agreeable watering 
place, may accomplish much good. Mental depression predis- 
poses to and aggravates this disease most markedly. Aran goes 
so far as to say that he has almost invariably found it present as 
inducing the disease. However this be, cheerful and congenial 
company certainly proves one of the best nervous tonics in a 
therapeutic point of view, and should always be sought for. A 
stay in a well-regulated hydropathic establishment, where the 
patient can have pure air, plain and nutritious food, and agreea- 
ble society, together with the strict attention to the general rules 
of hygiene which characterizes those institutions, will often pro- 
duce the best effects. 

Depletion, upon theoretical grounds, should be followed by 
most excellent results in corporeal uterine inflammation, and yet 
it is not so. So decided is my experience upon this point that I 
cannot but believe that that of others must be similar to it. As 
Nonat has pointed out, in cervical inflammation local depletion 
is productive of good results, for which we look in vain in cor- 
poreal disease. I have yet to meet with a case of corporeal 
metritis uncomplicated, be it understood, with cervical disease, 
which has been materially benefited by the most methodical and 
systematic local abstraction of blood, unless amenorrhcea was 
a symptom. In case this be so, a copious abstraction by leeches, 
during the menstrual epoch, will sometimes give relief. At times 
the leeches then applied will give great pain by their bites, under 
which circumstances they should at the next period be applied 
to the perineum. This pain from the bite of leeches applied to 
the cervix, is sometimes so severe as to lead to the apprehension 
that one has escaped into the cavity ; hence the importance of 
their being counted before being placed in the speculum, and on 
their removal from it. 

Emollients, which, applied externally, are so useful in acute 
metritis, and by the vagina so beneficial in chronic cervical 
inflammation, accomplish very little here. For purposes of clean- 
liness and relief of pelvic pains, copious vaginal injections should 
be employed ; sedative suppositories may be brought into rcqui- 



260 CHRONIC CORPOREAL METRITIS. 

sition for the latter of these purposes, and either entire or hip- 
baths be prescribed ; but further than this I do not believe that 
we can go with advantage. 

Alteratives. — Alterative remedies of a general character, as the 
iodide or bromide of potassium, should always be given a full 
trial, care being observed not to persist in their employment so 
long as to impair the tone of the stomach. Sometimes the fol- 
lowing prescription appears to be of benefit: — 

R. — Tr. cinchona? comp. %v. 

Hydrarg. bichloridi, gr. j. — M. 
A dessertspoonful in a claret glassful of water, three times a day. 

Should the affection have engrafted itself upon sub-involution, 
and metrorrhagia, or menorrhagia exist together with enlarge- 
ment of the uterine cavity, ergot, in moderate doses, may be 
administered for several months, in the hope of stimulating con- 
traction and absorption. Of the effects of all these drugs I am 
forced to speak very guardedly, for my experience does not enable 
me to express decided confidence in their efficacy. 

European writers speak in high terms of the alterative influ- 
ence of the various watering places and baths of the Conti- 
nent, as those of Marienbad, Schwalbach, Briicknau, and Kissingen 
in Germany, and of Saint Sauveur, Bareges, &c, in Switzerland. 
None of these equal in reputation the waters of Kreuznach in 
Germany, the curative property of which is supposed to depend 
upon the bromide of magnesium which they contain. It is very 
probable that the hygienic and social influences which surround 
these places and render them attractive, are to be credited with 
all the good that they do. Aran, after admitting that the water 
of Vichy may exert some influence, thus pointedly expresses him- 
self with reference to the others: "Whatever be their composi- 
tion, in whatever countries they may be found, I know of no 
work in which we can find the approximation to a demonstration 
in their favor." 

In a very limited number of cases the cavity of the uterus will 
be found so tolerant of applications, and even of the presence of 
foreign substances, that alteratives of local character may be 
employed with safety, but in the majority of cases such means are 
attended by danger, and are impracticable. The practitioner 



': COUNTER-IRRITATION. 261 

must, after careful experimentation, determine as to whether they 
should be resorted to or not, and they should never be used with- 
out the fact that they are capable of setting up a train of danger- 
ous symptoms, being kept constantly before the mind. When 
the case is one admitting their use, local alteratives unquestionably 
accomplish good in this disease. : They may be employed in two 
methods ; the os may be fully dilated by tents once every fort- 
night, and the entire uterine cavity painted over with pure tinc- 
ture of iodine or a strong solution of the iodide of potassium ; or 
the drug employed may be brought into contact with the walls 
of the uterus by means t>f medicated tents. Sponges cut into 
proper shape for tents, having been soaked for a week or more 
in a strong solution of the bromide or iodide of potassium, or in 
the tincture of iodine, are moistened in a solution of gum acacia 
and wrapped in the ordinary way. One of these is passed to the 
fundus of the uterus at intervals of from ten to fourteen days, and 
allowed to remain in position, should it not create disturbance, 
for twenty-four hours. By this means not only do we avail our- 
selves of the alterative influence of the drug, which is kept for 
hours in contact with the absorbing surface of the uterus, but we 
also obtain that which is due to pressure by the expanding tent. 

Counter -irritation. — Counter-irritation by means of blisters, 
issues, setons, &c, has long been practised on the abdominal 
walls for this affection, and is now regarded with much confi- 
dence by many Gyneco]ogists. In some cases it is at once pro- 
ductive of great benefit, while in others it produces none whatever. 
The difference of action depends upon the existence or non-exist- 
ence of peri-uterine inflammation. Should peri-uterine cellulitis 
or peritonitis exist as a complication of metritis, the beneficial 
effects of counter-irritation will usually be marked, while if they 
be absent, the remedy will be fruitless. In employing this 
means, the practitioner should bear in mind that it is appropriate 
in the treatment of a complication, and not of the original affec- 
tion. 

There is only one method by which in pure corporeal metritis 
counter-irritation can be employed with advantage. It is this • 
Sims's speculum being introduced, and the uterus fixed by a 
tenaculum fastened in the cervix, the whole external surface of 
the neck, together with the surrounding vagina, is painted freely 



262 



CHRONIC CORPOREAL METRITIS. 



with Churchill's strong tincture of iodine. This may be repeated 
once a week for a length of time, care being observed not to 
allow a surplus of the fluid to pour over and inflame the vulva. 
This method of application, which I learned from Prof. Fordyce 
Barker, is beneficial in a certain class of cases — those in which 
dragging of the uterus upon the utero-sacral ligaments gives pain 
in the hollow of the sacrum. It is probably by relieving inflam- 
mation in these structures, and not in the uterus itself, that it 
proves useful. 



CHAPTER XIX. 

ULCEKATION OF THE OS AND CEEVIX UTEEI. 

This subject has given rise to a vast deal of discussion and 
acrimonious dispute among Gynecologists, of late years; some 
declaring that it is one of the most frequent of uterine disorders, 
while others have asserted, with equal positiveness, that it is of 
extreme rarity. Some have met with it in practice as a lesion 
of daily occurrence, while others of most extensive experience 
have never seen it, except of specific character. It must be evi- 
dent that this discrepancy could not have existed in the facts 
with which the observers dealt, and equally probable that it 
must have been technical, a mere difference of statement due to 
disagreement with regard to nomenclature. Those who denied 
to a peculiar granular degeneration of the part, the name of 
" ulcer," found ulceration to exist very rarely, while those who 
thus defined such a degeneration, reported it as of very common 
occurrence. Even now, there is much difference of opinion as to 
the propriety of applying the term ulceration to this state ; many 
still looking upon it only as one of the elements of cervical 
endometritis, as Dr. Robert -Lee did originally. That it is so, 
appears to me certain ; but it assumes such peculiar forms, and 
becomes of itself so absorbing a subject in a therapeutic point 
of view, that it appears necessary to treat of it apart. It cer- 
tainly does not present the features which are generally con- 
sidered characteristic of the process of ulceration elsewhere, yet 
as the term fulfils the purpose for which it is employed better 
than any other, and is too generally accepted and sanctioned to 
admit of alteration, I shall make use of it without further dis- 
cussion. 



264 ULCERATION OF THE OS AND CERVIX UTERI. 
VARIETIES OF CERVICAL ULCERATION. 

The vaginal surface of the cervix uteri is subject to ulcerations 
of various types, which, according to their character, exert a 
greater or less influence upon the health of the patient. They 
may depend upon inflammation originating in the mucous or 
parenchymatous tissues of the part, may be created by ichorous 
discharges, the result of inflammation of the cavities of the neck 
or body, or be due to some peculiar depravity of the blood, 
creating a vice of nutrition. All the common and generally 
admitted forms of cervical ulceration may be classed under the 
following heads: — ■ 

1st. The granular ulcer ; 

2d. The follicular ulcer ; 

3d The true inflammatory ulcer ; 

4th. The syphilitic ulcer ; 

5th. The corroding ulcer ; 

6th. The cancerous ulcer. 

THE GRANULAR ULCER. 

This variety of ulcer which has been described under the names 
of erosion of the cervix, granular degeneration, and abrasion, 
consists, as its name implies, in the development of a surface of 
granular character on the smooth face of the cervix and just 
within the os. 

Frequency. — Of all the varieties of cervical ulceration this is 
by far the most frequent. Yery often it exists for a length of 
time without any suspicion of its presence arising in the mind of 
patient or physician, and sometimes without causing symptoms 
which prove in any great degree annoying. At others, grave 
constitutional signs may be traced to it and entirely removed 
by its cure. 

Causes. — The great pathological feature, essential for this form 
of ulceration, is inflammation of the lining membrane of the cervi- 
cal canal, or of that covering the vaginal face of the cervix. This 
may be associated with parenchymatous inflammation, but whether 
the last exist or not, a certain amount of mucous inflammation 
must be present for it to occur. Whatever then excites cervical 
metritis or endometritis may prove indirectly a cause of granular 



PHYSICAL SIGNS. 265 

■ulceration, but certain influences which exert a deleterious effect, 
directly upon the cervico-vaginal covering and the os, will prove 
more directly causative. 
Examples of these are — 

Uterine displacements, causing friction against the cervix ; 
Abuse of sexual intercourse ; 
Vaginal or uterine leucorrhoea ; 
The use of pessaries ; 
Injuries to the os, in parturition. 

Symptoms. — Should the disease exist, with but slight implica- 
tion of the subjacent uterine tissue, very few symptoms may be 
present. Indeed, profuse leucorrhoea is sometimes the only one 
of which the patient will complain. The fact that other and 
graver symptoms generally show themselves, is a corroboration 
of the statement, that those morbid states are important elements 
in such cases ; for where we meet with true inflammatory ulcera- 
tion occurring in procidentia and unattended by uterine inflam 
mation or congestion, it is remarkable how little disturbance is 
excited by it. Ordinarily, these are the symptoms which will be 
noticed in a case of gravity : — 

Profuse bloody and purulent leucorrhoea ; 
Pain and hemorrhage after intercourse ; 
Menorrhagia or metrorrhagia ; 
Pain on locomotion ; 
Fixed pain in back and loins ; 
Tendency to spaneemia ; 
Nervous disorders and perhaps hysteria. 
Physical Signs. — Yaginal touch will often alone serve as a 
diagnostic means, for by it the cervix is felt to be covered by a 
velvety or granular surface, which, to the practised finger, is at 
once recognizable. But the speculum offers the fullest corrobo- 
ration or corrects any error committed by this means. By it, the 
cervix, more especially near the os, is seen to be covered by a 
mass of pus, which being removed lays bare an intensely red, 
granular, hemorrhagic looking space of greater or less extent, 
closely resembling the inner surface of the eyelids when affected 
by granular degeneration. The diseased surface does not appear 
depressed below, but sometimes even elevated above the sur- 
rounding mucous membrane. 



266 ULCERATION OF THE OS AND CERVIX UTERI. 

Course and Duration. — There is no proof existing that this dis- 
ease is ever recovered from without surgical interference, although 
as to its being impossible I am by no means positive. The de- 
generated surface may go on for an unlimited time pouring out 
pus and thus greatly impoverish the blood and cause the gravest 
constitutional results ; or the same unfortunate end may be reached 
earlier by spread of the morbid action up the canal and the 
induction of cervical endometritis and metritis. 

Pathology. — The granular ulcer is produced by one of three 
pathological changes in the tissues of the part ; removal of epithe- 
lium and erosion of villi ; removal of epithelium and hypertro- 
phy of villi; or eversion of the cervical mucous membrane. In 
the first instance, the ulcer is superficial and not hemorrhagic. 
The epithelial covering is first removed, producing what is called 
an abrasion, and the villi themselves are destroyed. In the second, 
after removal of the epithelium, the papillae or villi increase in 
size and length, and project forwards like granulations, the larger 
ones so compressing the smaller as to cause their death by atro- 
phy. Each of these papillae contains a looped capillary vessel 
which, becoming enlarged by its hypertrophy, and being entirely 
unprotected by epithelium, naturally tends to bleed. Sometimes 
the circulation, in the supplying vessels, is so much impeded 
that they become varicose. These two facts have caused the 
names of bleeding ulcer and varicose ulcer to be applied to the 
respective states. 

At times still another change occurs in this form of ulcer, 
giving rise to another name. Its surface becomes coated with 
false membrane, when the ulcer is termed diphtheritic. 

Eversion of the cervix is by no means a rare cause of granular 
ulcer. As a result of inflammatory engorgement, or in conse- 
quence of slitting the walls of this canal by surgical procedure, 
or the act of parturition, its lining membrane prolapses as the 
mucous membrane of the lids does in ectropion, and if not dis- 
eased at the time of displacement, very soon becomes so. At 
times the hypertrophy, which, under these circumstances, may 
take place in the crested folds of the everted cervical membrane, 
produces so great a degree of convolution and projection as to 
have caused the appellations of fungous ulcer or cocks-comb 



TREATMENT. 267 

granulation to be applied to it, according to Dr. Arthur Farre, 1 
though Scanzoni 2 regards this as merely an exaggeration of the 
villous hypertrophy recently mentioned. 

Varieties. — Granular ulcer is the genus to which belong as spe- 
cies the varicose, fungous, bleeding, and diphtheritic ulcers that 
have been described by various writers. It is hardly necessary 
to multiply names, to describe the almost endless variations which 
may develop themselves in papillary hypertrophy. 

Prognosis. — The prognosis in these cases is always good, though 
it may require a great deal of time to effect a cure, for this will 
not be permanent unless that of the coexisting cervical disease be 
accomplished. 

Treatment. — The cardinal point in the treatment of granular 
ulceration of the cervix uteri is this, to look upon the ulcer only 
as a local manifestation of diseased action in the cervix or body, 
which is the lesion to be treated. "We should regard it only as a 
symptom of a graver and more important morbid state which 
should always be kept in view, even if the symptoms ^produced 
by the ulceration rivet the attention chiefly upon itself. It not 
unfrequently happens, that one symptom of a disease will so dis- 
tress and harass a patient that remedial measures must be entirely 
directed to it, although the practitioner be aware of the fact that 
it depends on disease elsewhere located. An example of this is 
sometimes presented in the morbid state under consideration, the 
ulceration itself proving so annoying by its profuse discharge, 
and interference with the functions of the uterus and locomotion, 
as to call for prompt relief. Where the ulceration is the result ot 
inflammation confined to that portion of the cervical tissue im- 
mediately underlying it, the relief of the ulcer by the alterative 
and counter-irritant action of the means adopted to accomplish it, 
may effect the cure of the disease producing it, and the fact of the 
existence of such disease may not be recognized. But where it 
depends upon the irritation of the discharges from the cavity of 
the cervix, or body of the uterus, or upon deep-seated parenchy- 
matous disease, it is curable only by cure of these. 

Should it be discovered then, upon examination, that corporeal 

1 Supplement Cyc. Anat. and Phys., p. G95. 

2 Diseases of Females, Am. ed., p. 222. 



268 ULCERATION OF THE OS AND CERVIX UTERI. 

or cervical endometritis, or cervical or general metritis exist, as 
the main disease, remedial means should be directed to their cure, 
at the same time that the less important local trouble receives due 
attention. It may be asked if this be true, how is it that the mere 
application of caustics to the ulcer will so often effect a recovery 
without regard to other disease? The disorder which most com- 
monly induces granular ulceration is mucous or parenchymatous 
inflammation at the vaginal extremity of the cervix. The solution 
of continuity to which the caustics are applied, acts, after their 
application, as an issue, and they by derivative and alterative 
influence effect a cure. It is precisely in accordance with this 
principle that the practitioner, if called to treat a case of cervical 
inflammation, which is unattended by such solution of continuity, 
creates it by abrading the surface by a blister or the hot iron, and 
then cures the issue thus caused by such caustics as the nitrate 
of silver or chromic acid. It is common to hear physicians remark 
that they are more successful in treating cases of cervical inflam- 
mation accompanied by granular ulceration, than those which are 
free from it. The key to the explanation has been given above. 

Having presented these remarks and sufficiently insisted upon 
their importance, we now proceed to the study of the special 
treatment of the ulcers themselves. The diseased surface may be 
reached by three effectual methods, through the speculum, by in- 
jections and by suppositories. Caustic applications made through 
the speculum, exert upon this disease a most decided and unques- 
tionable influence, and should be resorted to in the commencement 
of treatment. The speculum having been introduced and the 
cervix cleansed, the solid stick of nitrate of silver, the warm iron, 
chromic acid, or acid nitrate of mercury should be thoroughly 
applied. 

The caustic treatment will be quite sufficient for ordinary 
granular degeneration, relieving, when repeated often enough, and 
conjoined with other appropriate treatment, not only this state 
but the pathological condition which induces it. 

When, however, the exuberant development of villi called, by 
Evory Kennedy I think, cocks-comb granulation, exists, it is well 
to snip the growths as close as possible to the mucous membrane 
by a pair of long-handled scissors, or even to scrape the surface 
until it is smooth, by means of the curette, before applying the 



TREATMENT. 269 

caustic. After this the same caustics may be used as for simple 
granular ulcer. 

Should eversion of the cervix exist, the hemorrhoidal mucous 
membrane should be at once removed by the scissors, or, if more 
easily done, by the curette, and should much gaping of the os be 
present, the actual cautery or lunar caustic be employed. I have 
spoken so fully elsewhere of the danger of producing cicatricial 
contractions of the canal and induration of the cervix that it 
requires no further mention here. In eversion, however, a certain 
amount of contraction is to be desired. 

When eversion of the cervical mucous membrane is due to 
slitting of the canal either for surgical purposes or by parturition, 
the condition may be cured by an opera- 
tion which consists in paring by long 
scissors the edges of the cervical fissure 
and passing deep sutures of silver wire 
so as to approximate them thoroughly. 
By this means the os is restored to its in- 
tegrity, and the everted mucous surfaces 
being placed face to face, friction against 
them is prevented. 

After any of the applications men- 
tioned, the patient should be kept in bed 

-,-,. jni . ... n Operation for eversion of cervix. 

and directed to use copious injections of 

warm water twice or three times a day, or this with glycerine, 
laudanum, or infusion of linseed or slippery elm added to it. At 
the end of ten days, if one of the more potent caustics have been 
applied, or a week if one of the milder, the speculum should be 
again used, when it will be found that the slough which was 
created has separated and been washed away. Should the surface 
which now presents itself look healthy, and as if inclined to heal, 
we may rely for hastening this process upon the milder altera- 
tives, and instead of making another caustic application, leave in 
contact with it a pledget of cotton saturated with equal parts of 
glycerine and solution of persulphate of iron, or of glycerine 
holding tannic acid in suspension (3ij of the latter to 5vj of the 
former). This pledget should have a string attached to it, in order 
that the patient may remove it. 

But applications should be made not only by the physician, who 




270 ULCERATION OF THE 08 AND CERVIX UTERI. 

will probably use the speculum not oftener than once a week; the 
patient should make them daily by injections and suppositories. 
The former should be thus employed : every night and morning 
a gallon of tepid or warm water containing one ounce of glycerine 
and one drachm of sulphate of zinc, or two of sulphate of alum, 
acetate of lead, or tannin, should be injected for a period varying 
from ten to twenty minutes. Or if it be found necessary to em- 
ploy a stronger astringent solution, a gallon of pure water may 
be used first, for the time mentioned, and then a medicated solu- 
tion, one quart in amount, be used for a short time afterwards. 

Medicated pessaries or vaginal suppositories may likewise be 
made of great service. A suppository may be made to contain 
twenty grains of oxide of zinc, or sulphate of alum; twenty grains 
of mercurial ointment ; five grains of iodide of lead, or ten grains 
of tannin ; to any one of which, should an anodyne be needed, three 
grains of the extract of belladonna may be added. These sub- 
stances may be made into a mass with powdered gum tragacanth, 
starch, or slippery elm, and glycerine, and the* ball covered with 
cocoa butter. They may be introduced by the finger, but by the 
use of the vaginal suppository tube, delineated on page 231, there 
is much greater certainty of their coming in contact with the dis- 
eased surface. Suppositories may be employed once or twice a 
day, but are decidedly more beneficial while the patient confines 
herself to bed. 

Dr. Simpson is in the habit of applying dry powders in the 
upper part of the vagina, and Dr. Sims of introducing a tampon 



Fig. 98. 




Sims's tampon placer. A piston passes through the handle. 

of cotton wool by means of the instrument represented in' Fig. 98. 
I have found patients complain so much of the difficulty of the 
introduction of instruments that I have used a simple tube of 
hard rubber penetrated by a piston. By this every night and 
morning after the use of copious vaginal injections of tepid water, 



THE FOLLICULAR ULCER. 271 

substances in powder may be placed in contact with the os. The 
following prescriptions will be found astringent, alterative, and 
emollient : — 

R. — Pulv. gum tragacanth, 
Pulv. calaminaris, 
Pulv. amyli, aa 5J. — M. 
S. — A drachm to be introduced night and morning. 

R. — Pulv. ulmi fulvse, ^j. 
Bismuthi sub. nit. ^j. 
Alumenis pulv. gss. — M. 
S. — A drachm night and morning. 

But very generally, caustic applications must be repeated, and 
sometimes often repeated, before cure is effected ; and a question 
of importance arises as to the frequency of repetition which is 
most beneficial. I am convinced that we often apply caustics too 
frequently, not allowing time for their stimulant effect to be 
developed. If a caustic is applied to an ulcer on the leg, it is not, 
unless for special -cause, repeated so soon as the slough separates, 
but the alterative action which it creates is fostered and turned to 
a good account by subsequent dressing. We should be guided 
by the same principles in treating cervical ulceration, and in 
doing so should not cauterize the diseased surface oftener than 
once a fortnight if it be lightly done, or once a month if after the 
use of the stronger caustics a sluggish aspect is still maintained. 

THE FOLLICULAR ULCER. 

This form of ulceration, though not so frequent as that last 
mentioned, is by no means rare. It consists in an inflammation 
of mucous follicles, which resemble those of the canal, and which 
are scattered over the vaginal face of the cervix, and exist even 
in the cavity of the womb. " The 1 cervical mucous cysts are lined 
by epithelium and basement membrane. They contain a small 
quantity of mucus together with granule cells. Those upon or 
near the margin of the os uteri may be sometimes observed to 
contain short papillae within their margin." A recollection of 
these facts is essential to a full understanding of the stages of this 
form of ulceration. 

1 Cyc. Anat. and Phys., p. 640. 



272 ULCERATION OF THE OS AND CERVIX UTERI. 

Pathology. — Follicular disease of the cervix shows three entirely 
different phases : 1st. A number of vesicles, equal in size to a 
millet-seed and filled with a fluid like honey, is noticed covering 
the part. These are due to repletion from retention of their secre- 
tion. 2d. These cysts are seen open, i. e., they have burst, and a 
follicular ulcer marks the former site of each. 3d. The papillae 
which they contain undergo hypertrophy and cause the appear- 
ance of red, elevated, hemorrhagic looking tubercles in place of 
the depressed ulcers just mentioned. For the thorough knowledge 
of these ulcers we are indebted, as for so much else relating to the 
anatomy and physiology of the uterus, to Dr. Arthur Farre. 

Varieties. — It will now be readily perceived how a variety of 
names have been applied to this disease when examined at dif- 
ferent stages. Follicular disease is supposed to be the source of 
the eruptive affections described by authors as acne, herpes, and 
aphthse of the uterus. 

Causes. — Like the granular ulcer, it is produced by anything 
exciting cervical metritis or endometritis, of which it is a com- 
plication. 

Prognosis. — Like the granular ulcer also, the prognosis with 
reference to it will depend in a great degree upon that of the 
disease which underlies it. Should this be severe, a very 
guarded prognosis should be made as to speedy cure ; and this 
remark applies equally well to the granular form. 

Treatment. — The contents of all the cysts should be evacuated, 
and their cavities thoroughly cauterized by a sharp point of 
nitrate of silver, chromic acid, or the acid nitrate of mercury. 
Should the second or third stage exist, the diseased surface 
should be cauterized thoroughly. Then treatment should be 
directed to the uterine affection which has produced the disorder. 
Should cervical metritis or endometritis be found to exist, as they 
very likely will, the treatment appropriate to them should be 
adopted. 

THE TRUE INFLAMMATORY ULCER. 

Yery little need be said of this form of cervical ulcer, further 
than clearly to announce the possibility of its occurrence, and 
the circumstances under which it is met. In procidentia uteri of 
long standing it is rarely absent, and the deep excavations, pre- 



THE SYPHILITIC ULCER. 273 

cipitous edges, and inflamed bases of the spots, leave no room for 
difference of opinion as to their nature. This form of ulcer is 
very rarely met with, except as the result of direct injury with 
coexisting parenchymatous congestion or inflammation. Thus 
it may arise from the injuries resulting from friction in prociden- 
tia and ante or retroversion, or from excessive coition, where the 
cervix is much enlarged and its parenchyma inflamed. 

Prognosis and Treatment need not detain us, since both will 
depend upon the more important uterine affection. Leeching, 
fomentations, counter-irritants, and rest, should be resorted to, 
just as if no solution of continuity existed, in a case of parenchy- 
matous inflammation. If due to procidentia, they may be re- 
lieved by simply keeping the uterus in place. 

THE SYPEIILITIC ULCER. 

Frequency. — Syphilis may affect the cervix uteri either as a 
primary or secondary disorder, though in neither form is it by 
any means common. It is now a settled fact that true chancre 
may locate itself upon the cervix, but not the less certain is it 
that it rarely does so. I have seen but one case in which I felt 
satisfied that a cervical ulcer was of this character. This was 
proved by inoculation, the most certain way in which a strictly 
reliable conclusion can be arrived at, and by corroborative evidence 
existing in the presence of syphilitic roseola without primary 
disease elsewhere. Dr. Bennet 1 states, that in his own prac- 
tice it has been very rarely met with, and quotes in confirmation 
of his own experience that of Eicord, Cullerier, Gibert, Du- 
parcque, and others. M. Bernutz, who has made, according to 
Becquerel, 2 a special study of this subject in the hospitals of 
Paris, describes chancres of the os minutely, dividing them into 
Hunterian, diphtheritic, and ulcerous, which resemble phagedenic 
very closely. With regard to secondary affections on the cervix, 
there has been considerable discussion — some reo'ardins: them as 
quite common, others as very rare. Becquerel, after careful re- 
search in the Lourcine Hospital at Paris, was convinced of their 
occurrence, and Bernutz describes mucous patches, vegetations, 
erosions, tubercles, and gummy tumors. I know of no more 
significant evidence of the rarity of these affections upon the 

1 Bennet on the Uterus, p. 350. 2 Mai. de FUterus, vol. i. p. 169. 

18 



274 ULCERATION OF THE OS AND CERVIX UTERI. 

cervix, than the fact that in the most recent work upon syphilis, 
now before the profession, a work remarkable for the thorough 
and comprehensive style with which it deals with all relating to 
that subject, almost no mention is made of syphilitic affections of 
the cervix. I allude to the work of my colleague, Prof. Bum- 
stead. 1 The author investigates the character of syphilis when 
affecting all parts of the body, even the lachrymal sacs, the mem- 
brana tympani, &c, but nowhere is any mention made of the 
disease appearing on the cervix, except a cursory statement that 
at Bellevue Hospital he had seen some remarkable instances of 
mucous patches thus located. The sign of the secondary disorder 
which we would most naturally expect to find in this site, would 
be the mucous patch, as it is one of the most frequent of all 
the manifestations of that stage ; but we are informed by Messrs. 
Davasse and Deville, 2 that of one hundred and eighty-six women 
affected by syphilis, and examined in reference to the location of 
its lesions, they were found on the cervix uteri but once. 

Course and Termination. — The primary affection being located 
on the cervix may affect the general system as from any other 
part, and as M. Gosselin has pointed out, instead of passing off 
rapidly, as it sometimes does, may become an ulcer of ordi- 
nary appearance, or assume the fungous type. During its course 
the cervical chancre has a marked tendency to become covered 
by false membrane as Eobert 3 first noted, and Bernutz subse- 
quently corroborated. 

Differentiation. — For evident reasons, this is a matter of great 
importance, not only as regards therapeutics, but because it may 
involve a delicate legal question affecting the chastity of the 
woman. 

These are the means of diagnosis in case of chancre: — 

Border of ulcer precipitous; 

Surface of ulcer depressed ; 

Great tendency to bleed ; 

Great tendency to false membranous covering ; 

Rapid development of symptoms ; 

Early appearance of roseola ; 

Transmission by inoculation. 

1 Bumstead on Venereal Diseases. 

2 Davasse and Deville, Des Plaques Muqueuses : Arch. Gen. de Med., 1845, t. 
ix. et x. 3 Aran. Mai. de l'Uterus, p. 524. 



THE CORRODING ULCER. 275 

All of these signs are of value, but the only one upon which a 
positive opinion could be based is the last. 

Secondary eruptions, as, for example, mucous patches, vegeta- 
tions, &c, which appear here will be known by — 
Their rapid development ; 
Their connection with constitutional signs ; 
Simultaneous affection of the vagina ; 
Absence of chronic cervical inflammation ; 
The peculiar appearance of secondary eruptions ; 
It is, however, often very difficult to say with any degree of 
positiveness whether an ulcer is of this character or not. 

Treatment. — This will consist, in case of chancre, of the ordinary 
treatment elsewhere adopted. In case of secondary affections the 
patient should be put upon a mercurial course, the surface cauter- 
ized, and subsequent dressings made of mercurial preparations of 
which the black or yellow wash, mercurial ointment, or calomel, 
are the best. 

THE CORRODING ULCER. 

This term was applied by Dr. John Clark, of England, to a 
peculiarly intractable, indeed a uniformly fatal, ulcer, which com- 
mences in the mucous membrane of the vaginal face of the cer- 
vix, and in process of time destroys that structure and gradually 
the entire organ. 

Although there are many points of similarity between this dis- 
ease and cancer there are several in which it differs very essentially 
from it. Thus, cancer generally gives severe pain, while corrod- 
ing ulcer does not ; cancer involves the surrounding tissues, this 
rarely does so to any great degree ; cancer destroys life rapidly, 
this does so so slowly, that years may pass before it reaches the 
fatal issue. 

Authorities upon Gynecology and Pathology are, at present, 
almost unanimous in reference to the fact that the disease called 
corroding' ulcer is epithelial cancer of ulcerating form, and that 
it bears to the uterus very much the same relation that lupus or 
cancroid ulcers do to the face. All this will be fully investigated 
when the subject of cancer is taken up. It appears out of place 
to treat of it in the same category with the less important ulcera- 
tions of the cervix, and its consideration will be deferred until 
other malignant affections receive attention. 



276 ULCERATION OF THE OS AND CERVIX UTERI. 
THE CANCEROUS ULCER. 

All the varieties of cancer, encephaloid, colloid, and scirrhus, 
may show themselves in the uterus, which more frequently than 
any other organ of the body is the seat of their invasion. All 
these consist in a deposit of a lowly organized material, which 
subsequently undergoes disintegration. In the destruction of this 
material the part of the uterus in which it has found its nidus is 
destroyed likewise, and as it is most commonly in the cervix 
that it collects, the resulting solution of continuity creates a can- 
cerous ulcer. To one unfamiliar with uterine affections this might 
at its commencement be mistaken for a benign ulcer, but such an 
error will rarely be made. Its consideration will be postponed 
for the subject of cancers to which it properly belongs. 

In addition to these varieties of ulcer of the cervix, a scrofu- 
lous ulcer has been described by Lisfranc, 1 Robert, 2 Blatin, 3 
Duparcque, 4 and others. More recent works make no men- 
tion of it, or if they do, it is only to express disbelief in its 
existence. Dr. West 5 quotes to prove that the combined testi- 
mony of Robin, Lebert, and Hanover is in strong opposition to 
the occurrence of such an ulcer on the cervix, and Rokitansky, 6 
in describing these affections, makes no mention of having met 
with it. The descriptions given of it too by Robert, who has 
most minutely described it, and of others who record cases, ap- 
pear so much like those of cancer that very little doubt will be 
left in the minds of most readers as to its identity with that 
class of affections. 

The French school of Gynecology has always laid great stress 
upon the existence of certain diatheses as resulting in uterine 
ulcerations, and thus a great number of varieties will be found 
created by a supposed connection with them. Examples 7 of these 
are the herpetic, scorbutic, scrofulous, dartrous, tuberculous, 
arthritic, &c. &c. I refer to them not to advise the adoption of 
the nomenclature, but lest the student in his researches may meet 
with and be confused by their mention. 

1 Clin. Chirurg., vol. iii. p. 548. 2 Des Affections du Col de l'Uterus. 

3 Mai. des Fernmes, p. 521. * Mai. de la Matrice, vol. i. p. 394. 

6 Op. cit., p. 269. e o p . cit., vol. ii. p. 220. 

7 Blatin and Nivet. Op. cit., Ch. Ulceration. 



THE CANCEROUS ULCER. 277 

In concluding this subject, it may serve a good purpose to pre- 
sent at one view all the varieties of ulcers which have been 
described by the most recent authors, and to class each species 
under its proper genus. I would not recommend the student to 
employ the names of the varieties, for I believe that they can 
readily be dispensed with, the generic terms fulfilling every prac- 
tical purpose. To be familiar with the modern literature of the 
subject, however, he should be acquainted with them, as allusion 
to them will be often met with. 
1st. Granular ulcer. 

Fungous or cockscomb ulcer; 
Bleeding ulcer ; 
Yaricose ulcer ; 
Diphtheritic ulcer. 
2d. Follicular ulcer. 
Uterine acne ; 
" herpes ; 
" aphthae. 
3d. True inflammatory ulcer. 
Indolent ulcer ; 
Callous ulcer ; 
Diphtheritic ulcer. 
4:th. Syphilitic ulcer. 
Chancre ; 
Syphilides. 
5th. Corroding ulcer. 
6th. Cancerous ulcer. 



CHAPTEE XX 



GENERAL CONSIDERATIONS UPON DISPLACEMENTS OF THE UTERUS. 



History. — That the earliest practitioners of medicine were 
familiar with this subject is abundantly attested by the writings 
of the Greek and Roman schools. It is distinctly mentioned by 
Hippocrates, and more clearly and exactly still by Galen and 
Moschion about the second century of the Christian era. This 
remark applies not only to prolapse, but also to versions which 
were evidently understood. Hippocrates and Moschion even de- 
scribed latero-version, a variety which has not been much noticed 
by modern writers. There is no evidence, however, that they 
understood the difference between versions and flexions. 

Passing over many centuries, at the middle of the eighteenth 
we find Gynecologists paying attention to versions, and even to 
flexions, of the pregnant uterus, but losing sight of these dis- 
placements in the non-pregnant organ. Versions were at that 
period described by Garthshore, W. Hunter, Jahn, and Des- 
granges; and flexions, by Saxtorph, Wltczek, Baudelocque, and 
Boer. 

Denman was the first writer who describes flexion of the non- 
pregnant uterus, which he did in reference to a case of retro- 
flexion about the year 1800. The wanting link was not supplied 
until M. Ameline, of France, described anteflexions in 1827. 
For our present improved views upon the subject we are indebted 
most eminently to the following observers : — 

M. Bazin, Paris 

M. Ameline, Paris . 

Mine. Boivin and M. Duges, Paris 

Simpson, Edinburgh 

Amussat, Paris 



Bennet, Edinburgh 



1827. 
1827. 
1833. 
1813. 
1813. 
1815. 



SIGNIFICANCE OF VERSIONS AND FLEXIONS. 279 

Subsequently to the last date, the subject was gradually merged 
into the common stock of medical knowledge and admitted into 
all systematic works on Gynecology. I have not of course 
attempted to enumerate all writers upon it, but only those who 
have accomplished some improvement or suggested original 
views. Bazin deserves the credit of being one of the earliest 
modern writers. Ameline not only that but the additional merit 
of having been the first to fully describe flexions and differ- 
entiate them from versions, Boivin and Duges introduced the 
subject in a systematic work upon Gynecology, and Amussat 
improved our knowledge of it as it occurred during the pregnant 
state. But all these results were only foreshado wings of the emi- 
nent services of Simpson, who opened the way to diagnosis by 
introducing the uterine sound. At a still later period, Dr. Ben- 
net, by insisting upon the fact, which Lisfranc had stated, but 
failed to impress, out of France, that inflammation is very gene- 
rally the cause of displacement, accomplished for the subject 
scarcely less than his compatriot. 

Pathological Significance of Versions and Flexions. — The ancients 
ascribed to these displacements many constitutional evils, as 
paralysis, hysteria, &c, and even until a very recent period they 
were credited with a great deal of pelvic pain and functional 
uterine disturbance which it was supposed almost universally 
attended them. Until 1854 this belief prevailed very generally, 
having the powerful support and indorsement of such men as 
Yelpeau, Simpson, and Valleix. It is true that this view was con- 
tested by Cruveilhier and Dubois, 1 before the period mentioned; 
but at that time a spirited discussion arose concerning it, in the 
Academy of Medicine of Paris, which not only threw much doubt 
upon it, but gave rise to a powerful opposition, in the ranks of 
which appeared Depaul, H. Bennet, Aran, Becquerel, and others 
equally eminent. They maintained that these displacements of 
the womb, if unaccompanied by textural lesion, produced no con- 
stitutional disturbance, created, as a rule, no discomfort, and did 
not deserve the attention in treatment which had been bestowed 
upon them. They did not believe that the dislocation was the 
cause of suffering when this existed alone, but looked upon it, in 

1 Goupil, B. & G., op. cit., p. 459. 



230 DISPLACEMENTS OF THE UTERUS. 

such cases, as an epi phenomenon engrafted upon some more im- 
portant lesion. Consequently they were opposed to reliance 
being placed upon support by pessaries as one of the essentials of 
treatment, as had been done by the other school. 

TVhen views supposed to be false are repudiated, those adopting 
new ones are always apt to run too far into an opposite extreme, 
and in this instance many have done so. Scanzoni 1 sounds the 
keynote of this extreme party when he states that " flexions of 
the womb do not acquire any importance, nor are followed by any 
serious dangers, save when they are complicated with an altera- 
tion in the texture of the organ/' 

To refute the first part of this statement we shall not have to 
seek far, for the same author, ten pages farther on in his work, 
remarks that, ' ; in well-marked flexion, the canal of the neck is 
always more or less impermeable, which opposes an insurmounta- 
ble obstacle to conception." This is an open avowal that flexion 
is of importance without complication with alteration in the tex- 
ture of the uterus, and for further proof I would appeal to the 
experience of every practitioner, whether he has not seen it a 
cause of severe obstructive dysmenorrhcea. The following pro- 
positions may, I think, be presented as embodying the present 
opinions of the majority of the enlightened Gynecologists of our 
day. 

1st. Versions and flexions of the womb may exist without 
causing any symptoms, for in themselves they do not constitute 
disease. Thus it is that we see the uterus forced completely out 
of its place by tight clothing, without the production of morbid 
sigms. 

2d. By interfering with escape of menstrual blood, by disorder- 
ing uterine circulation, by causing pressure and friction from 
contact with surrounding parts, and by creating a barrier to the 
entrance of seminal fluid, they become of great importance and 
require special attention. 

3d. Generally being the results and not the causes of uterine 
and peri-uterine inflammations, they are best treated by alleviation 
of these states. 

•ith. Treatment by pessaries is rarely effectual, for we generally 

1 Op. eit., Amer. ed.. p. 112. 



NORMAL ANATOMY. 281 

reach only a symptom and not the disease in this way. Some- 
times, however, it becomes necessary after removal of the causa- 
tive lesions to prevent their return and to combat resulting 
relaxation of uterine supports. 

Definition and Synonymies. — The term displacement is applied 
by British and American writers to any decided removal of the 
uterus from its normal position, without reference to the direction 
in which it has been moved, while French writers apply the term 
displacement only to ascent and descent, reserving that of devia- 
tion for versions and flexions. 

Normal Anatomy. — The uterus is delicately poised in the pelvis, 
and prevented from descending to its floor by three agencies : the 
vaginal walls, which abut upon the sphincter vaginae muscle ; a 
surrounding investment of areolar tissue, which binds it to the 
bladder, the rectum, and the pelvic walls ; and four ligaments, 
which attach it to neighboring points of support. Of these means 
the most demonstrable and important is unquestionably the 
vagina, loss of tone in which will in time generally result in the 
accident which we are considering. A great deal of support is 
likewise derived from the connective areolar tissue, which so 
closely unites the uterus with the rectum and bladder as to involve 
displacement of these viscera in its descent. 

From the posterior face of the neck, there run two folds of 
peritoneum which go to the rectum. These inclose corresponding 
bands of fibrous tissue which attach the cervix to the sacrum, and 
have received the name of utero-sacral ligaments. Their influence, 
as likewise that of two similar bands connecting the cervix in 
front with the bladder, cannot be doubted. 

These are probably all the influences which unite in prevention 
of prolapsus in the first and second degrees. When they are 
entirely overcome and the descent has become complete, the 
round and broad or lateral ligaments come into action, but not 
until that has occurred. Some very interesting experiments upon 
the cadaver instituted by Dr. Henry Savage 1 prove these state- 
ments conclusively. 

From retroversion, the uterus is prevented by the round liga- 
ments, two fibrous cords which pass from the fundus to the pubis, 

1 On Female Pelvic Organ. 



282 DISPLACEMENTS OF THE UTERUS. 

the broad ligaments, which attach it to the pelvic walls, the two 
utero-sacral ligaments, which connect the neck with the sacrum, 
and the two columns of the vagina. Anteversion, which is gene- 
rally associated with flexion, is guarded against by less numerous 
and less effectual means. The presence of the bladder, the broad 
ligaments, and the columns of the vagina are the only preventives. 
None of these means of suspension are concerned in flexions 
and inversions, which are combated by forces of entirely different 
nature. The tissue of the unimpregnated uterus is of such strong 
resisting character in the adult female, as to prevent too great a 
curvature of the body upon the neck either anteriorly, laterally, 
or posteriorly. It is to this peculiarity of structure that immu- 
nity from these conditions is due. 

When stimulated by pregnancy or the presence of an intra- 
uterine growth, the uterine tissue develops rapidly into muscular 
structure. This keeps the cavity of the organ closed by tonic 
contractions, and removes the possibility of inversion unless it 
be accomplished by absolute violence. But when from any cause 
it is destroyed and the condition of tone is replaced by one of 
atony, flexion or inversion may occur. 

It is manifest that a number of mechanical influences may force 
an organ thus sustained upwards, downwards, backwards, laterally, 
or even bend it upon itself or turn it completely inside out, and 
that the direction of the impelling force, or nature and position 
of the loss of support will determine the character of the displace- 
ment. The displacements which may thus result have received 
the following appellations : — 

Ascent ; 

Descent or prolapsus ; 

Anteversion ; 

Anteflexion ; 

Retroversion ; 

Retroflexion ; 

Lateroversion ; 

Lateroflexion ; 

Inversion. 
These varieties should not be memorized by the students, for 
such an effort would be uncalled for. Let him suppose any pear- 



NORMAL ANATOMY. 283 

shaped bag, one of gutta-percha, for instance, suspended by yield- 
ing supports in any cavity, and it must be evident that these, and 
only these, changes of location could be impressed upon it. 
The general causes producing these results are the following : — 

1st. Any influence which increases the weight of the uterus ; 

2d. Any influence which diminishes the supports of the uterus; 

3d. Any influence which pushes the uterus out of place ; 

4th. Any influence which displaces it by traction. 

1st. The uterine supports are equal to sustaining the organ when 
of normal weight ; but when this weight is doubled they naturally 
fail in their task. 

2d. Even if the uterus be no heavier than it should be, it may 
become displaced from depreciation of that support to which it is 
entitled, and which was made to sustain it. 

3d. If both the uterus and its sustaining powers be perfectly 
normal, it is evident that direct or powerful pressure must over- 
come the latter and force the organ from its place. 

4th. It is equally evident that as by a tenaculum fastened in 
the uterus of the cadaver, we may drag it from its position, so 
may contracting lymph, or shortened ligaments, affect it in a 
living body. 

All these facts being admitted, a concise view of the principal 
causes of displacements may be thus presented : — • 

1. Influences increasing weight of uterus. 

Inflammation or congestion ; 

Tumors in the walls or cavity ; 

Pregnancy ; 

Hypertrophy ; 

Sub-involution ; 

Fluid retained in cavity ; 

Masses of cancer or tubercle. 

2. Influences vjeakening uterine supports. 

Rupture of the perineum ; 
Weakening of vaginal walls; 
Stretching of , uterine ligaments ; 
Want of tone in uterine tissue ; 
Degeneration of uterine tissue. 



i 



281 DISPLACEMENTS OF THE UTERUS. 

3. Influences 'pressing the uterus out of place. 

Tight clothing ; 

Heavy clothing supported on the abdomen ; 

Muscular efforts ; 

Ascites ; 

Abdominal tumors ; 

Abscesses or masses of lymph ; 

Eepletion of the bladder. 

4. Influences exerting traction on the uterus. 

Lymph deposited in pelvic areolar tissue; 

Lymph deposited on peritoneum of pelvic viscera ; 

Cicatrices in vaginal walls ; 

Shortening of uterine ligaments. 
The mode of action of each of these causes is so evident as to 
require no special mention at this time, but they will be particu- 
larly alluded to hereafter. This is all that need be said upon 
the subject of uterine displacements in general. I shall now pro- 
ceed to complete the outline here sketched, and to go into the 
details connected with each variety of the affection. 



CHAPTEB XXI. 

ascent and descent of the uterus. 

Ascent of the Uterus. 

In its normal condition the uterus descends into the pelvic 
cavity so as to assume a position about two inches from the vulva. 
If its weight be augmented it comes much lower than this, and 
continues to do so as its volume increases, unless its development 
becomes so great that it cannot be accommodated by the pelvis. 
Then it escapes from the cavity by ascending to a more capacious 
space above the superior strait. This fact is displayed by every 
normal pregnancy. During the first three months the uterus falls 
in the pelvis, being in a state of prolapse. As the fourth month 
approaches its volume becomes so great that it can no longer be 
retained in the pelvic cavity, and then it escapes above the supe - 
rior strait, where sufficient space is afforded for it to undergo 
full development. 

The uterus is similarly affected by morbid growths, and when, 
under these circumstances, it leaves the pelvis, the fact is ex- 
pressed by the term ascent. 

Ascent of the uterus is never an original disease, but the result 
of some important change connected with that organ, and requires 
merely a mention. It may occur whenever a tumor is developed 
in connection with the vagina, rectum, or recto-vaginal cul-de-sac, 
or when there exists a growth in the walls or cavity of the uterus 
which renders it too large for entrance through the superior strait. 
It never requires treatment, and is of importance only as exciting- 
suspicion of pregnancy, or as an evidence of morbid growth in 
connection with the organs of generation. 



2s6 ascent and descent of the uterus. 

Descent or Prolapsus of the Uterus. 

Definition, Synonymes, and Frequency. — The name of this disorder 
defines its character with sufficient clearness. It is of frequent 
occurrence, and under the name of Falling of the Womb, is 
well known to women, and constitutes for them an object of 
especial dread. As almost all women, after the period of fruit- 
fulness has passed, have an intuitive fear of cancer of the uterus, 
so do a large number before that time manifest an apprehension 
of prolapsus. In the one case the anxiety is for life, in the other 
for usefulness. 

Pathology. — It matters not whether the original cause of the 
displacement be increase of uterine weight, relaxation of support, 
or direct force exerted upon the organ, an invariable result of its 
existence is diminution of the power of the uterine supports. The 
ligaments are stretched, the vagina distended and doubled upon 
itself or everted, and the contractile power of the sphincter vaginae 
impaired. The displaced organ is very generally affected by con- 
gestion or inflammation, its cavity much enlarged, and inflamma- 
tory ulcers are found upon the cervix. The vaginal rugae are 
effaced, and the lining of the canal exposed to atmospheric influ- 
ences and friction, looks like the cicatrized surface of scalded skin 
rather than mucous membrane. 

Varieties. — This displacement may occur very suddenly «and 

unexpectedly, or gradually and by successive steps. As the 

symptoms of the two varieties differ only in the rapidity and 

severity of their development, and the second 

Fi §- "• is much the more frequent, I shall direct my 

remarks chiefly to it, and describe the first 

in a few words in an appropriate place. 

Prolapsus may exist either in the first, se- 
cond, or third degree, the direction of the ute- 
rine axis in each of which is exhibited in Fig. 99. 
In the first the uterine axis is unaltered, the 
organ having merely sunk in the pelvis. In 
Di l gr Z rep ; esenting f the second the body has gone towards the 

the three degrees of . 

prolapsus. sacrum, the cervix having come down upon 

the resisting ellipse formed by the sphincter 

vaginae. In the third the last barrier has been overcome, and 




CAUSES. 



287 



either a part or the whole of the uterus hangs between the thighs. 
This has received the name of procidentia. 

Fig. 100. 




Prolapsus in the third degree. (Boivin and Duges.) 

Causes. — The causes especially inducing descent of the uterus 
are most completely combined in the state existing after par- 
turition. The uterus is heavier than normal, the recently dis- 
tended vagina relaxed and feeble, the uterine ligaments very 
much stretched, and the sphincter vaginas muscle weakened, or 
permanently injured by rupture of its perineal union. But other 
causes which increase uterine weight may act in the same way, 
as tumors, polypi, inflammatory engorgement, &c. The uterine 
supports may likewise be injured by causes acting in the non- 
pregnant state, as senile atrophy of the vaginal walls, stretching 
the uterine ligaments by the pernicious habit of tight lacing, 
prolonged and violent exercise of the abdominal muscles, &c. 
The affection is very often met with in old women, when it is 
generally due to atrophy of the vaginal walls. 

Course, Duration, and Termination. — The condition is unlimited 
in its duration, and, unless relieved by art, will continue inde- 
finitely. It impairs the patient's comfort and capacity for exer- 



288 ASCENT AND DESCENT OF THE UTERUS. 

tion, but rarely has a fatal termination, unless by exciting peri- 
toneal inflammation, as I have seen it do in one case. 

Symptoms. — The symptoms of prolapsus are dependent upon 
two results growing out of the displacement, the mechanical inter- 
ference of the womb with surrounding parts, and alteration in- 
duced in its tissue by reason of its disadvantageous position. The 
uterus may remain even in the third degree of descent without any 
marked symptoms, but generally congestion, effusion, and ulcera- 
tion occur, which render it sensitive and intolerant of pressure or 
friction. At the same time, by dragging upon the bladder, rec- 
tum, and all the pelvic areolar tissue and fasciae, and by protrud- 
ing between the labia, it produces discomfort which often impedes 
locomotion to a great extent. The most prominent of the symp- 
toms thus created are the following : — 

Sensation of dragging and weight in the pelvis ; 

Eectal and vesical irritation ; 

Pain in back and loins ; 

Menorrhagia ; 

Great fatigue from walking ; 

Inability to lift weights ; 

Leucorrhoea and other signs of chronic metritis. 
Physical Signs. — All the symptoms detailed will only excite 
suspicion and prompt an examination which will fully elucidate 
the case. Should the affection exist only in the first degree, the 
finger passed up the vagina will meet with the os low down in 
the pelvis and pressing upon its floor. As it is slid upwards in 
front of the cervix and along the base of the bladder, the resisting 
anterior wall of the uterus will be clearly distinguished, and it 
may be found that anteversion or anteflexion exists, complicating 
prolapsus. 

If the second degree have been arrived at, the os will be found 
at the ostium vaginae, prevented from escaping only by the resist- 
ance of the sphincter, and the body, instead of lying forward, will 
be to some extent retroverted. 

Sight and touch will combine in making a rapid and easy diag- 
nosis in the third degree of falling, but even here I have known 
very grievous errors committed. The apparent ease of the diag- 
nosis sometimes causes error by inducing neglect of that caution 



COMPLICATIONS. 289 

and watchfulness which even in the simplest cases of disease con- 
stitute the only safeguard of the physician. 

Differentiation. — In any of its varieties prolapsus uteri may be 
confounded with fibrous polypus, inversion of the uterus, and 
elongation of the neck, from all of which, however, it is readily 
diagnosticated if the practitioner is awake to the possibility of error. 
From the first it is known by absence of the os and cervix, and 
the general shape of the mass. From the second by absence of 
os and cervix, and the presence of the signs of inversion. The 
third will readily be recognized by the great length of the cer- 
vix, the impossibility of replacing the supposed prolapsed organ, 
and the great depth of the uterus measured by the uterine probe. 
Prognosis. — The prognosis will depend upon the state of the 
uterus and vagina. Should the former be much enlarged from a 
fibrous tumor, or other disorder little amenable to treatment, no 
amount of support will prove sufficient to sustain it. On the other 
hand, even if the uterus be normal in weight and volume, the 
prospect of supporting it will be slight if the vaginal walls be 
greatly distended and have undergone much atrophy, for the 
vagina is the only natural uterine support which we can enlist 
by medical means. "Without treatment prognosis as to recovery 
is always very unfavorable. 

Complications. — Prolapsus of the uterus in its first and second 
degrees, and still more frequently in its third, produces the fol- 
lowing complications : — 

Congestion of the uterus and its appendages ; 

Endometritis and Fallopian salpingitis ; 

Chronic metritis ; 

Hypertrophic elongation of the cervix ; 

Cystocele ; 

Eectocele. 
In consequence of these, we very generally have as concomi- 
tant symptoms leucorrhcea, sterility, dilatation and eversion of 
the cervix, disorders of the bladder and rectum, and sometimes 
cystitis. The reason for the occurrence of these, will be appre- 
ciated by examination of Fig. 101. 

So frequent is the occurrence of hypertrophic elongation o^ the 
cervix, that in 1858 M. Huguier, of Paris, stated before the 
Academy of Medicine, in that city, that, as a general rule, those 
19 



290 



ASCENT AND DESCENT OF THE UTERUS 



cases regarded as being due to descent, were not so, but were 
instances of this elongation which produced eversion of the 

Fig. 101. 




Uterine mouth everted, bladder pulled down, and peritoneum stretched in both vesico 
and recto-vaginal cul-de-sacs. (Cruveilhier.) 



vagina. In 1860, he published a work in maintenance of this 
view, and strongly recommended as a remedy amputation of the 
hypertrophied part, or rather of as much of it as existed below 
the vaginal attachment. Since, for a great degree of uterine 
descent, a corresponding inversion of the vaginal walls is essen- 
tial, it follows very evidently that simultaneous displacement of 
the posterior wall of the bladder and anterior wall of the rec- 
tum, which are in close union with them, must occur. 

Sudden Prolapsus may come on from any great effort, a fall, 
or violent contraction of the abdominal muscles, acting upon a 
uterus which is enlarged by hypertrophy, subinvolution, preg- 
nancy, or tumors. In an instant the patient feels that something 
has given way within her, becomes prostrate and much alarmed, 
and suffers pain of expulsive character, as if desirous of forcing 
something from the pelvis. I have twice seen it occur within a 
fortnight after delivery from sudden and violent muscular effort, 
and once in a nulliparous girl of nineteen years. Should reduc- 
tion not be effected at once, violent pain will be felt over the 



TREATMENT. 291 

sacrum and groins, and the degree of traction exerted upon the 
pelvic peritoneum, may result in dangerous inflammation. 

Treatment. — The first indication as to treatment is to return 
the displaced organ to its normal position; the second, to keep 
it there. 

Methods of Replacing the Uterus. — In general no difficulty will 
attend the performance of the first indication, but in some cases 
careful and intelligent taxis will be necessary. The best method 
for applying this is the following: the patient, after thorough 
evacuation of the bladder and rectum, if this be possible, should 
be placed upon her knees and elbows, in order to cause gravita- 
tion of the pelvic and abdominal viscera towards the diaphragm. 
She should not kneel upon a soft or yielding bed, into which the 
knees would sink, but upon the floor or a covered table, for the 
object of the posture is to elevate the buttocks, and depress the 
thorax as much as possible. Ten or fifteen minutes should then 
be allowed to elapse before any efforts are made at reduction. 
In this time the intense congestion which exists in the pelvic 
viscera will greatly diminish. The operator then taking the 
cervix into the grasp of his index, middle, and ring fingers, the 
tips of which, thoroughly greased, are allowed to slide up as far 
as the vaginal junction, pushes the uterus firmly and forcibly 
upwards, in coincidence with the axis of the inferior strait. 
"While the right hand is thus employed, the left rests upon the 
back of the patient and steadies her body. No sudden or violent 
force is exerted, but by steady pressure kept up, if necessary, for 
fifteen, twenty, or thirty minutes, the uterus is restored to its 
place. 

Few cases will resist this kind of effort at reduction, although 
some may do so. For example, Dr. Alexander Monro has re- 
corded a case in which prolapsus occurred in a child three years 
of age, which proved irreducible, and resulted in death. If the 
uterus does not recede, I should regard it as firmly bound down 
by adhesions, the result of cellulitis, and hope for no benefit 
from other mechanical means, all of which are far inferior to this. 

Methods of Sustaining the Uterus. — Before pursuing any special 
course of treatment for this end, the practitioner should endeavor 
to discover the cause of the descent. If it be due to increase in 
the weight of the uterus, or to pressure exerted upon it from 



292 ASCENT AND DESCENT OF THE UTEEUS. 

above, it is evident that the indication will be very different from 
what it would be if the cause were enfeeblement of its supports. 
Unfortunately, however, after the disease has existed for some 
time, it is not possible to fix definitely upon the cause ; for even 
if it were increase of uterine weight, the long inversion of the 
vagina, and stretching of the uterine ligaments involved in its 
descent, will have destroyed all power in these parts. 

If a uterus be found prolapsed, whatever be the original cause 
of its dislocation, treatment can accomplish a cure only in one of 
two ways : — 

1st. By diminishing uterine weight ; 

2d. By strengthening uterine supports. 
As a general rule the practitioner confines himself to neither one 
of these, but fulfils both indications simultaneously. 

Means adapted to Decreasing the Weight of the Uterus. — This is 
best accomplished by the following means : — 

Eemoving weight of clothing by use of skirt- supporters ; 

Eemoving weight of intestines by prohibition of tight cloth- 
ing, use of an abdominal supporter, and avoidance of effort ; 

Preventing accumulation of urine and feces ; 

Eemoving polypi, tumors, &c, by operation ; 

Eemoving uterine inflammation and congestion by appropriate 
treatment ; 

Amputation of the neck of the womb. 

The skirt-supporter is merely a pair of suspenders which may 
be contrived by any .woman of ordinary ingenuity, and which 
enables the patient to carry the whole weight of the under gar- 
ments upon the shoulders. 

There are many varieties of the abdominal supporter, some of 
which, unfortunately, are so constructed as to do absolute harm. 
Should the compression be exerted by them upon the abdomen 
above the navel, it will tend to increase pressure upon the uterus, 
or at least to annul all the benefit of that exerted below this point. 
The principle upon which these supporters should act is this — they 
should do just what the patient's hands do when she places them 
above the pubis, and lifts the abdominal viscera. Some of them 
are composed simply of bands of thick cloth, others are pads or 
disks of horn or metal, with encircling bands like those of the 
hernial truss. The physician may choose between them intelli- 



TREATMENT. 293 

gently, if he only bears in mind what it is that he desires to 
accomplish by them. 

During the pursuance of this plan the patient should be limited 
as to exercise and confined to bed during menstrual epochs, when 
the uterus is known to be heavier than at other times. Should 
the accident have followed parturition she is similarly confined, 
to allow the accomplishment of involution. 

Amputation of the Neck. — Sometimes, by applying appropriate 
treatment to an hypertrophied cervix, the uterus is in time so 
much lightened that a cure is effected, but at others the hy- 
pertrophy is so persistent and rebellious that these means fail, 
and resort has been had to amputation of the neck. M. Hu- 
guier, of Paris, was, in 1848, the first to perform this operation 
for prolapsus, though it had long before been resorted to in 
cancer. Since that time it has been performed by many others, 
after methods which will be described in a chapter devoted to the 
operation. 

Should these means fail, or should we fear lest they alone may 
not be sufficient for the desired result, resort should be had to 
those which accomplish the second indication. 

Means for Strengthening Uterine Supports. — These may be thus 
enumerated : — 

The recumbent posture ; 

Local astringents and tonics ; 

Perineal support and perineorrhaphy ; 

Pessaries ; 

The operation of elytrorrhaphy' for lessening the dimensions 
of the vagina. 

It will be noticed that these means are chiefly directed to de- 
velopment of increased power in only one of the supports of the 
uterus, the vagina. This is not only from the fact that it is the 
most powerful factor in sustaining it, but also because we have 
no decided means by which the others can be affected. 

The recumbent posture, persistently persevered in, accomplishes 
a great deal of good in cases of prolapsus in the first and some- 
times even in the second degree. The buttocks beino- elevated, 
the uterus retreats from the pelvis, and its supports are left entirely 

' iXvrpov," the vagina," and px^v, "suture." 



294 ASCENT AND DESCENT OF THE UTERUS. 

at rest. Opportunity is thus afforded the weakened tissues to 
contract, to gain tone and strength, and in time to resume their 
functions. The results of posture may be materially increased by 
simultaneous employment of the following agents. 

Astringents and Tonics. — By these means the vaginal walls may 
be so strengthened as to sustain the uterus for a time, and thus 
keeping it out of danger of congestion from interference with 
circulation, opportunity is given for removal of engorgement or 
slight hypertrophy. 

The astringents most commonly employed are tannin, alum, 
persulphate of iron, and the bark of the white oak. They may be 
injected into the vagina in solution or infusion, by means of the 
ordinary syringe ; introduced in suppositories ; or applied to the 
whole canal in powder, by the vaginal suppository tube represented 
on page 231. By means of this the patient may every night upon 
retiring leave in contact with the cervix one or two drachms of 
powdered alum or tannin, or if these prove irritating, a semifluid 
mixture may be prepared with glycerine and starch and de- 
posited in the vagina by the same instrument. 

Tonics may be locally applied by the use of cold hip-baths, 
douches, sea baths, and by copious vaginal injections of cold 
water, salt and water, or, still better, sea water. Surf bathing is 
peculiarly beneficial in this capacity, for it not only acts locally, 
but improves the tone of the whole system. 

Perineal Support. — I have already pointed out the important 
function of the sphincter vagina in closing the mouth of the 
genital canal and offering itself as a buttress for the support of its 
walls. When rupture of the perineum occurs, its sphincteric 
powers are impaired and the result is sagging of one or both 
columns of the vagina and coincident descent of the uterus. By 
firm pressure at the weak spot, by means of a pad or cushion 
filled with hair, cotton, or air, and combined with an abdominal 
supporter, to which it may be attached, much relief is sometimes 
obtained. Where rupture of the perineum appears to have been 
the origin of prolapsus vaginae, which has resulted in descent of 
the uterus, the operation of perineorrhaphy, described on page 
115, may prove curative. But generally both this and episior- 
rhaphy, although efficient in cases of prolapsus vaginse, will prove 
insufficient where so heavy a weight as the uterus needs support. 



PESSAKIES. 



295 



Pessaries. — The plan of giving support to the procident uterus 
by means of bodies of greater or less density placed in the vagina, 
naturally suggested itself to the fathers of medicine, and at pre- 



Fig. 102. 



Fig. 103. 




Fig. 105. 



Coxeter's pessary. 
Fig. 105. 



Fig. 107. 




Zwanck's pessary. 



Zwanck's pessary of box-wood. 



sent they are still resorted to. The varieties most commonly em- 
ployed are the ring, the disk, the ovoid, the globular, the sponge, 
and the air pessary. All of these are open to one great objection, 
they are palliative and not curative; for while they sustain the 



296 



ASCENT AND DESCENT OF THE UTEEUS, 



prolapsed organ by their own force, by their bulk they prevent 
the vagina from contracting and in time becoming capable of 
resuming its duty. 



Fig. 108. 




Coxeter's modification of Zwanck's pessary. 
Fig. 109. 




Roser's pessary. 



Fia. HO. 



Fig. 111. 




Scanzoni's pessary. 



Hoffman's pessary shaped 
like the pelvis. 



The desideratum is an instrument which will not distend the 
vagina at the same time that it will support the uterus. Such 



ELYTEOERHAPHY, 



297 



instruments as those represented in diagrams 102, 105, 109, and 
110, relieve the vagina of all labor by assuming its duties without 
distending it and thus allow it to regain its former tone and power. 



Fig. 112. 



Fig. 113. 




Bourgeaud's pessary ; a is a caoutchouc 
bag filled with air. 



GarieFs pessary. 



Elytrorrhaphy. — The idea of constricting the vagina so as to 
diminish its capacity and at the same time offer a column of cica- 
tricial material for the support of the uterus, long ago suggested 
itself to the minds of practitioners for the relief of prolapsus uteri. 
In 1823 M. Eomain Grerardin made the suggestion before the Medi- 
cal Society of Metz, but the operation does not appear to have 
been essayed. In 1831 Dr. Marshall Hall, of England, again pro- 
posed it with modifications, and some years afterwards it was per- 
formed by Dr. Heming, the translator of Boivin and Duges on 
the Diseases of the Uterus, with complete success. Subsequently 
to this period it was performed, with various modifications, by 
Dieffenbach, Fricke, Scanzoni, Velpeau, Koux, Stolz, and others, 
the operation always consisting in, "the removal of a band of 
vagina] mucous membrane and union of the two lips of the wound 
in such a manner as to diminish the calibre of the vaccina. * * 
Dieffenbach refers to a great number of women who were com- 
pletely cured by the procedure. * * * * Fricke out of four 
cases cured three." 1 Judging from these quotations, it appears that 



1 Wieland and Dubrisay, op. cit., p. 533. 



298 ASCENT AND .DESCENT OF THE UTERUS. 

tlie operation has been known and practised for a long time on the 
continent of Europe, especially in Germany. In England it has 
not been resorted to, if we may judge from the statement of Dr. 
Sims,' that after a discussion upon an essay presented by himself 
to the London Obstetrical Society, Mr. Spencer Wells called his 
attention to the operation of Mr. Heming, already referred to, 
with the assertion that " at least one case had been successfully 
operated upon." 

Before the invention of Sims's speculum and method of vaginal 
exploration, this operation was practicable only by drawing the 
uterus down to the ostium vaginae, and in all probability the 
reason for its limited adoption was the difficulty attending its 
performance. I shall now proceed to describe Sims's method, 
which differs very essentially from that adopted by his prede- 
cessors. 

Sims's Operation of Elylrorrhaphy. — The patient being put under 
the influence of anaesthesia, is laid upon a table and Sims's largest 

Fig. 114. 




Sound with sharp points. (Sims.) 

speculum introduced. ■ The curved sound, with forked tenaculum 
points, represented in Fig. 114, is fixed in the cervix uteri and 
made to cause a fold in the anterior vaginal wall, as shown in 
Fig. 115. 

The parts being steadied by this instrument, the operator, by 
means of two tenacula, folds over the opposite walls of the vagina 
so as to decide where union is to be effected. Having settled this 
point, the mucous membrane is hooked up by a tenaculum, several 
lines above the meatus and cut by curved scissors. The tenacu- 
lum lifting the shred thus cut, and when necessary being again 
attached to the mucous membrane, the incision is carried upwards 
so as to cut out a strip extending to one side of the cervix. Then 

1 Uterine Surgery, p. 312, Am. ed. 



ELYTKOKKHAPHY, 
Fig. 115. 



299 




Uterus fixed by sound. (Sims.) 
Fig. 116. 




speculum and sound in position. (Sims.) 

another furrow is cut in the same manner on the other side as 
represented in Fig. 117. 



300 



ASCENT AND DESCENT OF THE UTERUS. 




Sims's operation of elvtrorrhaphy, 
sutures in place. 



Sutures of silk should then be. 
inserted after the plan employed 
in vaginal fistulas, and by them 
silver sutures are drawn into 
position. The passage of su- 
tures should be commenced at 
the apex of the triangle and 
continued upwards, the sutures 
being placed as represented in 
Fig. 117. 

Dr. Emmet finding that the 
pouch, left anterior to the ute- 
rine neck by this procedure, was 
sometimes entered by the cer. 
vix, improved the operation by 
closing it as represented in Fig. 
118. 

The sound being removed and 



Fig. 118. 




imet's operation of elytrorrhaphy. 

the cervix pulled down by a small tenaculum, the transverse line 
of denudation, shown in the diagram as uniting the two arms of 



ELYTRORRHAPHY. 801 

the V, is accomplished. The only further difference between this 
and the other method consists in quilting the suture. This is 
not properly shown by the diagram. 

The after-treatment consists in perfect quietude in the horizontal 
posture, the use of opium, frequent removal of urine by a catheter, 
and the production of constipation. The lower sutures may be 
removed in ten days, and the upper in a fortnight. The patient 
should be kept in the recumbent posture for two or three weeks, 
and cautioned against immoderate muscular effort for some time 
afterwards. 



CHAPTEE XXII. 
versions of the uterus. 

Anteversion. 

Definition and Frequency. — This disorder of position consists in 
an anterior inclination of the uterus, so that the fundus approxi- 
mates the symphysis pubis and the cervix retreats into the hollow 
of the sacrum. Although not so frequent as it's kindred condi- , 
tion, anteflexion, it is by no means of rare occurrence At times' 
it presents itself as an annoying complication of chronic metritis 
or fibroid growths, while at others it is produced without any 
alteration existing in the uterine parenchyma. 

Dr. Churchill 1 opens his chapter upon this subject with these 
words : " It may be thought somewhat out of place to treat of 
some of these displacements here, as they are so intimately con- 
nected with pregnancy and parturition; but as they do occur 
independently, it appears to me preferable to travel so far out of 
the way in order to complete the subject, rather than give a partial 
view, or omit it altogether." My own experience leads me to an 
entirely different conclusion from that here recorded by the emi- 
nent Irish obstetrician. I meet with versions very commonly in 
the non-pregnant state. At this time I have under treatment 
three cases of anteversion, one of which is due to corporeal metri- 
tis and endometritis, one to a small neoplasm, and a third, which 
produces very little disturbance, exists without assignable cause. 
M. Goupil, in 115 examinations of nulliparous women, met with 
version or flexion 14 times ; and in 114 examinations of multi- 
paras he found it in 36 instances. 

The normal position of the uterus is one of slight anteversion, 
the axis of the body corresponding with that of the superior strait, 

1 Diseases of Women, Am. ed. 




303 



Normal position of uterus. (Wieland and Dubrisay.) 

which, is a line running from the umbilicus, or a little above it, to 
the coccyx. 

The degree of this forward inclination may be so increased by 
slight causes as to constitute a morbid state. As to the line which 
separates what is normal from what is abnormal, it is impossible 
to lay down any exact rule; experience mast be our guide. In 
general terms, we may say that when the long axis of the uterus 
is found lying across the pelvis, the fundus near the symphysis 
pubis, and the neck in the hollow of the sacrum, anteversion 
exists. 

Causes. — The causes of anteversion may be thus presented at a 
glance. 

Influences increasing the weight of the uterus. 

Inflammation; 

Subinvolution ; 

Neoplasms ; 

Pregnancy. 
Influences forcing the fundus directly forwards. 

Yiolent efforts ; 

Abdominal effusions ; 

Abdominal tumors ; 

Tight clothing. 



304 VERSIONS OF THE UTERUS. 

Influences dragging the fundus directly forwards. 
False membranes ; 
Shortness of the round ligaments. 

A certain number of cases will be found due to metritis, a 
number by no means inconsiderable to fibrous tumors, some of 
the most irremediable cases to false membranes, while a few 
will exist without other apparent cause than direct pressure from 
some power which forces down the abdominal viscera upon the 
fundus. The last cause is much aided by laxity of the abdominal 
walls, which robs the viscera of support. 

In early pregnancy anteversion always exists, the increase of 
uterine weight due to that condition causing the uterus to fall 
forwards as represented in Fig. 120. 

Fig. 120. 




Position of the pregnant uterus. 

Symptoms. — As has been already stated, anteversion may exist 
without creating any disturbance either constitutional or local. 
When symptoms do exist with it, they are generally the result of 
the disease which produces it. At times, however, by pressure 
of the os against the posterior vaginal wall, it induces dysmenor- 
rhoea and sterility, and by pressure of the fundus against the 
bladder, and the cervix against the rectum, these viscera are 
irritated and interfered with in their functions. The bladder 
more especially suffers, sometimes a state bordering upon cystitis 



VARIETIES. 



305 



being engendered. Pressure upon the rectum more rarely pro- 
duces tenesmus and a painful, irritable state. 

Course, Duration, and Termination. — Very little need be said 
on these points, for they depend upon the peculiarities of the 
affections which have caused the displacement. If the cause be 
removed, whether it be metritis, fibrous tumors, direct pressure, 
or traction, the effect will disappear ; but until this is done no 
hope of permanent restitution can be indulged. 

Varieties. — Anteversion may be complete or partial. While 
there are three degrees of retroversion and of prolapse, there are 
but two of this displacement, for the axis of the uterine body is 
naturally inclined so much forwards as to prevent us from includ- 
ing slight increase of inclination under the head of disease. 

The following diagram, Fig. 121, will show the varieties referred 
to ; an inclination of 45° representing the first degree, or partial 
version, and that of 90° the second degree, or complete version. 
I have never met with the second degree, although it unques- 
tionably occurs. 

Fig. 121. 




The degrees of anteversion. 

Diagnosis. — "When in a case of this displacement the vaginal 
touch is practised, the patient lying on the back, the index finger 
20 



306 VEKSIONS OF THE UTEEUS. 

passed into the fornix vaginae discovers that the cervix is absent. 
A rapid investigation will prove that it is not to be found in the 
pubic or lateral regions of the pelvis, and deep exploration with 
two fingers will discover it high up in the hollow of the sacrum. 
The finger being then passed towards the pubis will come in con- 
tact with a hard ridge, which will run towards the symphysis. 
Conjoined manipulation will prove this to be the body of the 
uterus, and complete the diagnosis. Should further evidence be 
required, the uterine probe, very much curved, may be passed into 
the cavity, though this is rarely necessary and always difficult. 

Differentiation. — Capuron 1 tells us that Levret mistook the first 
case he saw for stone in the bladder, operated for this, and sacri- 
ficed the life of his patient. In spite of such a grave mistake at 
the hands of so great an authority, it may be stated that there is 
no diseased condition with which this should be confounded. The 
disease inducing the displacement may not be recognized, or 
some serious error may be made as to its nature, but that does 
not concern the present subject. The recognition of the mere 
fact of the anteversion is never difficult, if proper diagnostic 
means are brought to its elucidation. 

Prognosis. — The prognosis as to any serious injury which will 
arise from the displacement is decidedly good, but that as to cure 
is by no means so. It is generally very difficult to remove the 
cause, and even should this be accomplished, the uterus is so 
prone to retain the abnormal position in which it has been long 
kept, that great difficulty attends its restoration and retention. 
One of the reasons for this is the fact that the uterine ligaments 
readily alter their proportion under certain influences. Thus 
during pregnancy they are all elongated ; in posterior displace- 
ments the utero-sacral ligaments are stretched ; and in anterior 
inclination the utero- vesical ligaments are similarly affected. As 
the antithesis of this fact, prolonged absence of function causes 
contraction in these structures ; thus in anteversion, as Dr. Sims 
has pointed out, the utero-sacral ligaments are generally short- 
ened, and there can be no doubt that the round ligaments are 
similarly altered. 

Treatment. — The first point which the practitioner should settle 
before commencing treatment, is whether the displacement is the 

1 Mai. des Femmes, p. 202. 



MEANS FOR REDUCTION. 307 

main source of existing morbid phenomena, or whether these are 
due to some disease which underlies that condition. If he be led 
to regard the disorder of position as the disease, its rectification 
by artificial support must constitute the chief object of his atten- 
tion. But if he views it merely as a result of metritis, fibrous 
tumor, or pelvic peritonitis, his only hope of relieving it must 
rest in the cure of the special disorder which is its source. It 
should not be concluded, however, that treatment by artificial 
support must be confined to cases of pure, uncomplicated displace- 
ment, for it is very often required where this is the result of dis- 
ease. We are called upon to alleviate one of the most annoying 
symptoms of disease here, as we are in so many other instances. 
Pessaries are frequently applied to the uterus as splints are to 
the fractured femur, not as a means of cure, but as adjuvants in 
treatment by which rest and freedom from pain can be procured 
while the healing process advances. 

Means for Reduction. — In the restoration of an anteverted uterus 
to its place, difficulty will rarely be experienced, for unlike re- 
troversion, the displacement does not often become complete. 
Even when it does so, reduction may be thus accomplished. 

The bladder having been emptied by the catheter, the patient 
should be placed upon her back on a hard bed or table, and all 
tight clothing removed from the abdomen. Her shoulders should 
be unsupported, and her buttocks very much elevated by pillows. 
The operator having oiled two fingers should then pass them into 
the vagina, and press their tips against the body of the uterus, 
which will have forced the walls of the bladder down before it. 
The fingers of the right hand being thus employed, the left should be 
laid upon the abdomen, so as to push up the abdominal viscera and 
uterus when reduction is attempted. The patient is now directed 
to fill the lungs with air, and then to expel it gently by a pro- 
longed expiratory act. As this expiration is being finished, the 
operator presses up the body of the uterus by the fingers in the 
vagina, and the abdominal viscera and fundus by the hand on 
the abdomen. He will very generally at once succeed in replac- 
ing the organ. Should he not do so, he should repeat the pro- 
cess as above described, until the end is attained. Of course 
where the dislocation is partial, restoration may be much more 
easily effected ; but in this case it accomplishes nothing — for no 



308 VERSIONS OF THE UTERUS. 

sooner does the force applied cease, than the organ again falls out 
of place. In such a case the fundus is lifted by bi-inanual mani- 
pulation, then the hand on the abdomen keeping it up, the finger 
in the vagina is placed behind the cervix, and this part is pulled 
forwards towards the symphysis. 

Some practitioners rely for cure upon the daily restoration of 
an anteverted or retroverted uterus — but hopes thus based will 
prove delusive. Where the version is complete and sudden, a 
return to normal position may be final ; but never have I, in a 
single instance, seen it so result where the displacement was 
incomplete and gradual. 

Means for Retaining the Uterus in Position. — For this purpose 
we have the five following means : — • 
The dorsal decubitus ; 
Prolonged retention of urine ; 
Eemoval of pressure from the abdomen ; 
The abdominal supporter ; 
Pessaries ; 
Elytrorrhaphy. 

The dorsal decubitus in cases occurring suddenly, as for ex- 
ample during pregnancy or after labor, is of great value, but in 
chronic cases it cannot be relied on, for the patient should not be 
confined to bed. Even here, when practised for two or three 
hours at mid-day, it gives great relief. 

Prolonged retention of urine was first recommended by Piorry. 
It is a means of no great value, but is certainly worthy of trial. 

Removal of Abdominal Pressure, by prohibition of tight clothing, 
of heavy skirts supported by the hips, and of all constricting 
bands which cause a substitution of abdominal for thoracic respi- 
ration, is too often neglected in these cases. It is a means of 
great value, and often gives more relief than any other at our 
command. 

The Abdominal Supporter. — In proportion to the disadvantages 
resulting from corsetting the upper segment of the trunk, are 
the advantages to be derived, in these cases, from thus acting 
upon the lower. When the abdominal walls are lax and yield- 
ing, and do not properly sustain the viscera, they fall upon the 
fundus uteri, and tend to produce and keep up anterior obliquity. 

No one can deny that by a well-fitting abdominal supporter, 



PESSARIES. 



309 



tone is given to the lax walls, and that the intestines, not the uterus, 
are sustained. I have already stated that many are prejudiced 
against this means, and decry it as absolutely injurious; but I see 
it too plainly and certainly productive of good results in daily 
practice to admit of any doubt in my mind concerning it. 

Pessaries. — These instruments generally accomplish nothing 
in cases of anteversion, but in exceptional instances they are of 
benefit, and therefore should be tried. The ring pessary of Prof. 
Meigs, the block tin ring of Sims, or the pelvic pessary of 
Hoffman, represented on page 296, will prove most generally 
applicable. They act, not by rectifying the displacement, but 
by simply lifting up the uterus and diminishing pressure against 
the bladder. 

In some cases the air pessary of Gariel, combined with the 
abdominal supporter, answers a good purpose. Although no 




Fig. 123. 




Gariel's air pessary in place. 
Dubrisay.) 



(Wieland and 



Operation for shortening anterior 
vaginal wall. (Sims.) 



single resource will surely effect a good result, all of those men- 
tioned, employed in combination, will often be successful. 

Elytrorrhaphy. — Should they fail, we ma}^ resort to an operation 
recommended by Dr. Sims as having been successful in his 
hands, which consists in shortening the anterior wall of the 
vagina. This operation applied to the purpose indicated, has as 



310 



VERSIONS OF THE UTERUS, 



yet been very little tried, but it is worthy of attention from the 
facts that it commends itself to the reason, and comes to us 
indorsed by excellent authority. It is thus described by Dr. 
Sims : two surfaces a half inch wide, and running nearly 
across the anterior wall of the vagina, the one in juxtaposition 
with the cervix, and the other an inch and a half or more ante- 
rior to it, are to be denuded of mucous membrane. They are 
then brought into apposition by silver sutures, the patient put to 
bed, and the stationary catheter introduced. At the end of a 
fortnight the sutures may be removed, when the wall operated 
upon will be found shortened, so as to draw the cervix towards 
the symphysis. It is represented by Fig. 123. 

Eetroversion. 

Definition and Frequency. — Eetroversion consists in a posterior 
inclination of the uterus, so that the fundus approaches the sacrum 
and the cervix advances towards the symphysis pubis. As an 
idiopathic primary lesion, it is of extreme rarity, but it is fre- 

Fig. 124. 




Retroversion of the uterus. 



quently symptomatic of inflammatory disease or other states which 
increase the weight of the uterus. 



KETKOVERSION. 311 

Causes. — These may be classified under four heads : — 
Influences increasing uterine weight. 

Neoplasms ; 

Subinvolution ; 

Metritis ; 

Pregnancy ; 

Eesults of parturition. 
Influences dragging the uterus out of place. 

Adhesions from pelvic peritonitis or peri uterine cellu- 
litis. 
Influences forcibly displacing the uterus by direct pressure. 

Severe succussion by blows or falls ; 

Muscular efforts ; 

Distended bladder ; 

Tumors ; 

Management after parturition. 
Influences weakening uterine supports. 

Pregnancy ; 

Tumors ; 

Eelaxation of vagina ; 

Eupture of perineum. 
As might be presumed from the natural anterior obliquity of 
the uterus, anteversion not unfrequently occurs as an idiopathic 
lesion, resulting from pressure of superincumbent viscera forced 
down upon the fundus by tight clothing or muscular effort. Of 
retroversion this is seldom true. It generally depends upon some 
pathological state in the uterus or its appendages. The third class 
of causes mentioned as retroverting the organ by direct pressure, 
may act through violent succussion and induce sudden displace- 
ment with symptoms of most urgent character. By prolonged 
pressure from a distended bladder or from a tumor anterior to or 
above the uterus, it may likewise induce gradual displacement. 
Anteversion is most commonly encountered in unmarried women, 
while retroversion occurs generally in those who have borne 
children. A little reflection will explain how the management of 
parturient women, by British and American practitioners at least, 
favors the occurrence of the accident. In the first place, it must 
be remembered that pregnancy combines in itself two of the influ- 
ences which are productive of the condition, increa'sed weight and 



312 VERSIONS OF THE UTERUS. 

relaxed support. It is no exaggeration to assert that the usual 
plan of management after parturition supplies one of the others 
which are mentioned above. The woman lying almost constantly 
upon her back, the heavy fundus naturally tends to fall back- 
wards into the hollow of the sacrum. Many nurses insist upon 
this position and often for days refuse the patient the privilege of 
lying upon the side. But this is not all, many a nurse's reputa- 
tion among ladies rests upon her capacity for " preserving the 
figure" by tight bandaging. A powerful woman will often 
expend her whole force in making the bandage as tight as possi- 
ble to accomplish this purpose. No one who has watched the 
process can doubt its influence in displacing the uterus by direct 
pressure. There is no practice connected with the lying-in 
room, to which so much of almost superstition attaches as to the 
use of the obstetric bandage for preservation of the figure and 
prevention of hemorrhage. 

Varieties of Retroversion. — It may exist in slight degree, the 
uterine axis inclining so as to make with that of the superior 
strait an angle of 45° ; or it may incline to 90°, thus lying across 
the pelvis; or the cervix maybe thrown up and the fundus 
descend so as to form an angle of 135°. These varieties are 
known as the first, second, and third degrees of retroversion. 

Symptoms. — Although retroversion is often itself a symptom, it 
creates disturbances which without its existence would not have 
shown themselves. For this reason it is difficult to determine what 
elements of the case are due to it, and what depend upon the dis- 
order producing it. It may exist without adding anything to the 
catalogue of symptoms, as proved by the fact that its removal 
accomplishes nothing in the way of relief; but very often it creates 
tenesmus of bladder and rectum, together with a low grade of 
inflammation in the lining membrane of these viscera; fixed, gnaw- 
ing pain in the back; discomfort in locomotion; and pain in 
defecation. But these are not sufficient for diagnosis, and often 
do not excite suspicion as to its existence. It is generally dis- 
covered by vaginal touch. These remarks do not apply to sudden 
retroversion, the result of succussion, in which variety the symp- 
toms are marked and severe. The patient falls to the ground and 
is unable to rise, experiences the severest pelvic pain, suffers from 
suppression of urine and feces, and is often in such agony that 



PHYSICAL SIGNS 
Fig. 125! 



313 




The degrees of retroversion. 

the face is bathed with perspiration and the pulse becomes weak 
and fluttering. 

Physical Signs. — The finger being introduced into the vagina 
discovers an absence of the cervix from its usual place, and upon 
further investigation finds it near the symphysis pubis. Upon 
passing backwards to the sacrum it meets a resisting ridge which 
ends in a hard, round mass, resting upon the rectum. The size, 
rotundity, and distinctness of this will depend upon the degree of 
the displacement. In the first degree the resisting line but no 
tumor will be felt ; in the second, a slightly rounded mass ; and 
in the third, the fundus with its characteristic form will be appre- 
ciated. Should doubt remain as to the nature of the mass thus 
felt, the rectal touch, uterine probe, and conjoined manipulation 
will remove it. 

Differentiation. — This affection may be confounded with fibrous 
tumor on the posterior uterine wall, and the results of pelvic 
peritonitis or cellulitis. A little attention to the direction of the 
uterine axis as demonstrated by the position of the cervix, the 
use of conjoined manipulation, and the passage of the uterine 
probe will usually settle the question at once. 



314 



VERSIONS OF THE UTERUS. 



Fk. 126. 




Prognosis. — This will depend to a great degree ■upon the disease 
of which the displacement is a symptom. Generally this will be 
metritis of parenchymatous variety, the prog- 
nosis of which is by no means flattering. As 
a general rule, we may say that retroversion 
is an obstinate and most persistent complica- 
tion of uterine diseases, and that its relief can 
never be positively promised, unless it be the 
result of succussion, pregnancy, or some other 
temporary influence. 

Results. — This displacement may produce 
the following disorders : — 

Dysmenorrhcea ; 
Sterility ; 
Cystitis ; 
Kectitis. 
Treatment. — The first indication is to restore 
the uterus to its place, the second to prevent 
its again becoming displaced. 

Means for Reduction. — The bladder and rec- 
tum having been evacuated, and the clothing 
loosened, the patient is made to kneel upon a 
hard surface, and to place the sternum as 
closely as possible in contact with the plain 
which supports her. The practitioner then oils 
two. fingers and carries them into the vagina 
and against the fundus. He then directs the 
patient to fill the chest with air, and expel it 
completely. As she does so he forcibly ele- 
vates the fundus and restores it to its place. 
Should this plan fail, the buttocks should be 
still more elevated by placing cushions under 
the knees and the attempt repeated. 

If it cannot be restored in this way, Sims's 
repositor is the best instrument for the pur- 
pose, and we should resort to it. This instru- 
ment, which is represented by Fig. 126, con- 
sists of a short metal sound A terminating in a ball C. The^ball 
is clasped by a straight shaft, moves upon a pivot running 




Sims's uterine repositor. 



MEANS FOR RETENTION. 



315 



through its centre, and is perforated by seven holes. Through 
the shaft runs a rod which is projected by a concealed spring, 
that is governed by the finger passed through the ring B. The 
ball can be made to revolve so that the sound describes a half 
circle, by withdrawing the stop-rod which runs through the shaft 
and depressing the instrument. 

Fig. 127 represents the instrument introduced and reposition 
being accomplished by retracting the stop-rod and depressing the 
ball. 

' Fie. 127. 




Replacing a retroverted uterus. (Sims.) 



In the majority of instances reposition is perfectly practicable 
by conjoined manipulation or rectal taxis, or by means of two 
sponge-holders. 

Good results will often attend carrying a sponge staff up the 
rectum and another up the vagina, so as to make pressure upon 
the displaced fundus, after the plan adopted by Dr. Bond, of Phila- 
delphia, in his ingenious repositor, which is represented in Prof. 
Meigs's work on Midwifery. In replacing a uterus in this or any 
other malposition, the operator should never forget that inflam- 
matory action may have caused an effusion of lymph around it 
which resists its removal, and that if these adhesions are violently 
ruptured, cellulitis or peritonitis may result. Fig. 128 shows a 
uterus thus bound down. 

Means for Retention. — Having restored the organ to its normal 
place, the question which should next suggest itself is not how 



316 



VERSIONS OF THE UTERUS, 
Fig. 128. 




Uterus bound down by false membranes. (Picard.) 

to retain it there, but whether such retention is advisable, practi- 
cable, and void of danger ; whether the patient is suffering from 
symptoms especially referable to the displacement, or this is 
merely a sign of existing disease, upon which it exerts no influ- 
ence. If it be regarded as a symptom which is doing no evil of 
itself, the disease of which it is a result should be treated in the 
hope that this symptom will vanish with the disappearance of its 
other concomitants. Thus if metritis exists, it should be cured ; 
if a polypus, it should be removed, &c. &c. But if the primary 
disorder have disappeared and this one of its results remains, 
or if the original disease be still present, and the displacement be 
regarded as aggravating it, and adding to the discomfort of the 
patient, an effort should be made to overcome it by local means. 
Our resources for accomplishing this are the following : — 

Abdominal decubitus ; 

Attention to keeping the bladder empty ; 

The abdominal supporter ; 

Pessaries ; 

Perineorrhaphy. 
As I have alluded to the action of most of these methods in 
speaking of the treatment of anteversion, I shall not repeat my 
remarks here. With reference to pessaries and perineorrhaphy 



MEANS FOR RETENTION. 



317 



a few words will be necessary. In speaking of the use of pessa- 
ries in anteversion, I stated that they accomplished very little. 



Fig. 129. 



Fig. 130. 





Hodge's closed lever pessary. 



Hodge's open lever pessary. 



In retroversion, they are more efficient, and often result in decided 
relief. The instruments which will be found most useful are the 

Fig. 131. 




Scattergood's pessary, with spiral springs in branches. 

closed or open lever pessaries of Prof. Hodge, the block-tin pes- 
sary of Sims, the ring of Prof. Meigs, the spring-lever pessary of 
Scattergood, or the pelvic pessary of Hoffman. 

An excellent instrument for sustaining the retro verted uterus 
is that of Dr. Cutter, of Massachusetts. The inferior extremity 
of this pessary arches backwards over the coccyx and attaches to 
an elastic cord which passes upwards over the sacrum to a girdle 
around the waist. It is a painless and efficient method of giving 
support, and will gain a high reputation on account of these quali- 
ties, not only in displacement backwards, but, with a little altera- 



318 



VEESTONS OF THE UTERUS, 



tion, for those in an anterior direction. The class of cases to 
which it is especially applicable, is that in which the displacement 



Fig. 132. 



Fig. 133. 





Sims's block-tin pessary. 



Cutter's pessary. 



Fig. 134. 




Meigs's ring pessary. 



is due to enfeeblement of the posterior vaginal walls from rupture 
of the perineum or other cause. 

Messrs. Tiemann & Co. have recently modified and improved 
Meigs's ring pessary by making it of a very delicate watch spring 
covered by India rubber. It is so elastic as to 
assume any shape required by the pelvis, and 
answers an excellent purpose in patients who 
are so sensitive as not to be able to bear a less 
pliable support. 

Sometimes one of the stem pessaries, repre- 
sented on page 326, may be made to answer a 
good purpose. When no pessary can be tole- 
rated, a roll of cotton or bit of sponge saturated 
in glycerine, or, as is better, in a solution of sulphate of copper or 
zinc, may be packed in the space behind the cervix so as to be 
made to sustain the fundus. It was success by this plan in a very 
aggravated case which led Dr. Hoffman to devise the instrument 
represented on a preceding page. Whatever instrument be em- 
ployed should pass into the recto-uterine space, and sustain the 
displaced fundus without creating pain or discomfort. Should 
any such inconvenience be produced, it should be at once removed, 
for the most violent cellulitis may result. While a pessary is kept 
in the vagina, cleanliness should be secured by daily vaginal 
injections, and at intervals not exceeding two or three months it 
should be removed, examined, and reintroduced. They will some- 



MEANS FOR RETENTION. 319 

times produce severe ulceration, pass from the vagina completely 
through, the septum into the rectum or bladder, and in one case, 
under the care of Prof. Sayre, of the Bellevue Hospital Medical 
College, a large round pessary was found to have dilated the canal 
of the cervix and to have entered the uterine cavity. 

If the posterior vaginal wall needs support, which it has lost 
from rupture of the perineum, the operation of perineorrhaphy 
may be of great service. 



CHAPTEE XXIII 



FLEXIONS OF THE UTERUS. 



The uterus may be flexed upon itself anteriorly, posteriorly, or 
laterally, giving rise to the disorders known as — 

Anteflexion ; 
Eetroflexion ; 
Latero-flexion. 

Anteflexion. 

Definition and Frequency. — This, which is the most frequent of 
all uterine displacements, consists of a bending of the organ so 



Fig. 135. 




Anteflexion. (Wieland and Dubrisay.) 

that the fundus or cervix approximates the middle of the anterior 
wall of the uterus. 



ANTEFLEXION. 321 

Before puberty it is so frequent as to have been considered by 
Boulard, Verneuil, Follin, and others, as physiological. Whether 
it be so or not, this at least is proved, that before that time it does 
not constitute, nor depend upon, a morbid state. At that period 
of life it is probably due to the want of tone and power which 
characterizes undeveloped uterine tissue, for even if anteflexion 
does not exist, the organ will generally be otherwise displaced. 
Thus, M. Soudry, 1 in 71 post-mortem examinations of infants, 
found the uterus anteflexed 41 times, anteverted 11 times, retro- 
verted 15 times, retroflexed twice, and retroverted with ante- 
flexion twice. We may conclude from the evidence at present 
upon record : — 

1st. That anteflexion is the rule during early childhood; 
2d. That it is extremely frequent in nulliparous women ; 
3d. That in multipara it is, in proportion to other displace- 
ments, infrequent. 

Varieties. — There are three degrees of anteflexion: first, where 
the uterus is simply curved upon itself, "antecourbure," as Aran 
styles it ; second, where a decided flexion exists ; and third, where 
the cervical and corporeal portions of the organ are in close prox- 
imity. The following peculiarities are noted in different cases : — 

Sometimes the body is flexed upon the cervix ; 

Sometimes the cervix is flexed upon the body ; 

Sometimes both are flexed forwards ; . 

Sometimes the body is anteflexed and the cervix bent backwards. 
Pathology. — To a certain extent anteflexion of the uterus is 
prevented by the support yielded by the broad ligaments, which, 
passing from each side of that organ to the pelvic walls, sustain 
the weight of the fundus. The influence of these structures has, 
however, been greatly exaggerated with reference both to this 
accident and to retroflexion. That they are decidedly active in 
keeping the uterus upright and preventing versions, no one can 
for a moment doubt, but an examination of the pelvic organs 
upon the cadaver will, I think, convince the examiner that their 
power does not extend to a material prevention of reduplication 
of the uterus upon itself. This is chiefly accomplished by the 
inherent strength and resistance of the proper tissue of the organ. 

1 Aran, op. cit., p. 981. 

21 



322 FLEXIONS OF THE UTEKUS. 

Suppose a uterus composed of gutta-percha instead of muscle ; 
the material forming the walls of the neck will support the fundus 
when the pear-shaped bag is held by the stem or narrow part. 
To carry the simile further, so long as the proper tissue of the 
stem or neck remains normally strong, flexion will be impossi- 
ble unless its resistance be overcome by direct physical force 
exerted by pressure or traction. But if some influence be brought 
to bear locally, so as to soften the part sustaining the fundus, it is 
evident that as the gutta-percha wall grows weak, there may be 
a flexion of the fundus from its own weight. It will be said that 
these views represent the uterus as supported by the vagina only, 
and leave out of consideration the broad ligaments which sustain 
the fundus. If these ligaments were tightly drawn cords, I could 
admit their action, but as they are merely lax folds which are not 
made tense by the bending of the uterus upon itself, I do not do so. 
Causes. — As with the substance comprising such a bag, so is it 
with the tissue of the uterus. Its duty is to support the fundus, 
and for the performance of this it is abundantly competent, unless 
its function be defeated by one of the following influences : — 
Influences weakening uterine support. 

Inflammatory softening of the neck ; 

Pregnancy ; 

Fatty degeneration; 

An undeveloped state of uterine parenchyma. 
Influences increasing the weight of the fundus. 

Inflammatory enlargement of the body ; 

Pregnancy ; ' 

Fibrous tumors. 
Influences pushing the fundus or cervix forwards. 

Abdominal tumors ; 

Ascites ; 

Fecal accumulation ; 

Tight clothing ; 

Muscular efforts. 
Influences exerting traction forwards. 

False membranes from pelvic peritonitis or peri- 
uterine cellulitis ; 

Shortness of round ligaments. 
Of the first class of causes, inflammation affecting the parenchyma 



SYMPTOMS — DIAGNOSIS. 823 

of the neck and impairing its strength is, according to my experi- 
ence, one of the most frequent, though Virchow denies its occur- 
rence, as lie likewise does the agency of fatty degeneration observed 
by Scanzoni, at the point of flexure. The influence of parturition, 
abortion, and pregnancy has been admitted by all authorities. 
An undeveloped state of the parenchyma of the uterus is a fruit- 
ful source of anteflexion. This in part explains its frequency in 
infants, virgins, and nulliparae, and the fact that it is often cured 
by pregnancy and parturition. Dr. Noeggerath, whose attention 
has been especially directed to this point, dissents from the view 
here adopted and, believes that shortness of the round ligaments 
accounts for the frequency of anteflexion in the virgin, and the 
stretching of these by parturition explains its greater infrequency 
after the occurrence of that process. The varieties coming under 
the head of the second set of causes are all universally admitted, 
as are also those belonging to the third. Fecal impaction may 
sometimes produce flexion of the body, and frequently' causes the 
cervix to bend sharply forwards. The fourth set of causes is 
beyond question, the uterus in autopsies being often found thus 
bound in a state of flexion. 

Symptoms. — Anteflexion, pure and simple, that is, uncompli- 
cated by disease, is not accompanied by symptoms unless it so 
obstruct the uterine canal as to prevent ingress and egress of 
fluids. Unless such obstruction exists, the symptoms attending it 
will be due to metritis or endometritis, and not to the mere dis- 
placement. 

Diagnosis. — As the finger passes into the vagina and touches 
the cervix, nothing abnormal will be discovered. But as it 
sweeps along the anterior wall of the uterus, about the os inter- 
num a protuberance will be met with which presses upon the 
bladder. The finger which has thus far explored being kept in 
contact with this mass, the disengaged hand should then be laid 
upon the abdomen and made to depress the anterior abdominal 
wall so as to approximate the finger in the vagina. By this 
means the shape, size, and sensitiveness of the body may be 
ascertained. The diagnostician is, however, still in doubt whether 
the enlargement may not be one due to fibrous tumor or cellulitis. 
This point he settles by placing the patient on the side, introduc- 
ing Sims's speculum and gently probing the uterus to the fundus. 



324 FLEXIOXS OF THE UTERUS. 

Giving to the probe the curve which by the vaginal touch he has 
been informed is that of the uterus, he carefully passes it in. 
Should it not proceed without obstruction, he withdraws it, alters 
the curve, and tries again. Having introduced it, he learns the 
course of the uterine canal, its length, and the sensitiveness of its 
walls. Should the probe have entered the mass felt in the vagina, 
that mass is the uterine body. Should it go in the normal axis or 
backwards, it is not the uterine body but some growth in contact 
with it. 

Prognosis. — Whatever be the cause, the prognosis of this dis- 
placement is very unfavorable, with reference to cure. Fortu- 
nately, if its evil results can be prevented or removed, the 
flexure need create no anxiety — for in itself it is not of great 
importance. 

Treatment. — The indications for treatment are very simple : to 
restore and retain the flexed part, or, failing in this, to remove 
obstruction created by the flexion, while the mal-position is 
allowed to continue. The fulfilment of the first alone is unim- 
portant, as the part restored to position falls out of it, so soon 
as the restoring power is removed. It must be borne in mind 
that flexions are unlike versions in respect to rapidity of pro- 
duction. Versions may occur suddenly from some violent dis- 
turbing influence, under which circumstance they are susceptible 
of immediate relief. V?e have no proof that flexions are ever 
thus induced, unless occurring in advanced pregnancy. They 
are the consequences of influences long kept up, and can never 
be overcome with any reasonable hope that they will not imme- 
diately recur. 

Means for Preventing a Recurrence. — And now arises the im- 
portant question, are there any means at our command by which 
anteflexion can be counteracted ? Its answer is this : direct and 
immediate prevention is beyond attainment by any safe means at 
our command, but, indirectly, we may by perseverance accom- 
plish it. Should the practitioner discover, for example, that 
metritis is the source of the evil, it should be treated ; if it result 
from pregnancy, the dorsal decubitus should be observed until 
the unfavorable circumstance has passed away ; and if it arise 
from arrest of development of the parenchyma, growth should 
be stimulated by sponge tents, the galvanic pessary, &c. If tight 



MEANS FOR PREVENTING A RECURRENCE. 325 

clothing or abdominal effusion appear to have produced the 
flexion, the remedy is self-evident, as it is, likewise, if the neck 
has been sharply bent forward by fecal impaction. 

The propriety of this course is a plain and valid deduction, 
but in practice it unfortunately often fails in effecting a cure. 
The disorder which has been productive of the lesion may be 
removed, and yet the result remain. Under these circumstances, 
or where flexion exists so as to produce dysmenorrhoea and 
sterility, without the coexistence of any other morbid state, what 
are we to do for its relief? It is evident that but two courses 
are open to us, to maintain the displaced part, or to leave it in its 
abnormal position, and prevent as far as possible its resulting 
evils. 

In speaking of the treatment of versions, a variety of means 
for their relief were enumerated. Not one of these proves effi- 
cacious in anteflexion. Abdominal and vaginal supports are 
useless, unless it be in relieving a certain amount of version 
which complicates the flexion. They avail nothing in obviating 
the flexion itself. Recognizing our poverty of resources in cases 
of version, M. Velpeau, 1 between thirty and forty years ago, con- 
ceived the very plausible idea of restoring the uterine axis to 
its normal direction, by introducing a stem to the fundus, and 
retaining it there. After experiment he abandoned it, and sub- 
sequently Amussat followed in his steps, both in essaying and 
casting it aside. In 1848, Prof. Simpson again brought it into 
notice in versions and flexions, and met with a warm ally in M. 
Valleix, of Paris. This instrument, known as the intra-uterine, 
or stem pessary, unquestionably counteracts directly and imme- 
diately both versions and flexions. But it has been found to 
cause metritis and death in a number of instances, and in conse- 
quence it has been almost entirely abandoned. In this city, I 
am led to believe that it is very rarely employed, from the facts 
that I never hear it mentioned as a resource, and that at a recent 
discussion upon displacements in the Obstetrical Society, it was 
never once alluded to. In an essay read before the New York 
State Medical Society, last year, Dr. Peaslee advocated its use, 
and stated that in his hands it has produced good results. 

1 Discussion in Acad, de Med., reported in Charleston Med. Journ., 1853. 



;26 



FLEXIONS OF THE UTERUS. 



It is beyond question that in exceptional cases, and in such 
cautious hands as those of the writer last alluded to, the stem 
pessary may be productive of good, but a faithful trial of the 
instrument for twenty years by capable practitioners in different 
parts of the world, has not returned a verdict in its favor. It is 
difficult to explain the encomiums once showered upon it by its 
advocates, and the remarkable cases reported from the use of an 
instrument now viewed with disfavor by the great majority of 
practitioners. Nonat seems to have solved the paradox in declar- 
ing that, carried away by enthusiasm, " ils se sont laisses aller 
trop facilement sur le terrain glissant des illusions." Yet who 
will hesitate to indorse the sentiment expressed by Malgaigne, 
in the discussion upon the subject in the Academy of Medicine 
in Paris, in 1852, that, " a treatment which Amussat, Velpeau, 
Simpson, Huguier, and Valleix had tried, cannot, should not, be 
considered as repugnant to common sense?" 

Intra-uterine pessaries should be used with the greatest caution ; 
the uterus should be prepared for tolerance of the foreign sub- 
stance by trials of one, two, or three hours for a week before 



Fig. 136. 



Fig. 137. 





Peaslee's stem pessary. Detschy r s stem pessary. (Wieland and Dubrisay.) 

their introduction, and after it the patient should be carefully 
watched in order that the instrument may be removed on the 



OBVIATING THE CONSEQUENCES OF FLEXION. 327 

first symptom of metritis. Even the most ardent advocates of 
stem pessaries will admit the necessity for these precautions, and 
even their bitterest opponents must allow that with them as a 
safeguard, in certain cases they should be resorted to. To cast 
them entirely aside when such high authority recommends them, 
would be irrational and unj ustiflable. 

Figs. 136 and 137 represent the intra-uterine pessaries most 
commonly employed. 

Means of Obviating the Consequences of Flexion. — The reader 
should bear in mind these facts : — 

1st. That flexion as an independent condition is often incurable ; 
but that, in compensation, uncomplicated flexion is often not pro- 
ductive of symptoms, and calls for no treatment ; 

2d. That when complicated by morbid states, flexion may be 
much relieved by their removal ; 

3d. That when flexion results mechanically, in evil symptoms, 
we may frequently remove these by surgical interference. 

If a piece of stiff tubing be bent, the calibre of its canal will 
be obliterated at the point of flexure in proportion to the acute- 
ness of the angle created. In the same manner is the uterine 
canal affected by the lesion under consideration. The obstruction 
created in this way prevents the free escape of menstrual blood, 
which distends the cavity of the uterus and forms clots within it, 
and these at each period are expelled by uterine tenesmus. In con- 
sequence of this inflammation of the mucous lining of the uterus 
arises, that in time may produce parenchymatous disease, which 
favors further displacement by the increase of uterine weight 
attending it. The effort required for expelling clotted menstrual 
blood constitutes painful menstruation, and the same obstruction 
which retards egress of fluids interferes with ingress and prevents 
conception. Thus it is that we so often meet with the following- 
conditions as complicating flexions, sometimes as its causes, but 
at others as its results : — 

Endometritis ; 
Metritis ; 
Version ; 
Dysmenorrhoea ; 
Sterility. 

Having been forced to accept the displacement as an irreme- 



328 



FLEXION'S OF THE UTERUS. 



diable evil, we now endeavor to strike at the source of the patho- 
logical series which results from it by overcoming obstruction at 
the point of flexure ; in other words, by substituting a straight for 
a crooked canal. This can be accomplished by cutting through 
one wall of the cervix. 

If the posterior wall, in a case of anteflexion, be cut towards 
the vaginal junction so that a probe will pass into the uterus in 
the direction of the line a d, the obstruction resulting from the 
existence of an angle will be removed, and thus fluids may have 
free entrance and exit. The mechanical principle of the pro- 
cedure is explained by Fig. 138. 

Fig. 138. 




Creation of new uterine axis, a b represents the axis of the hody ; b c represents 
the axis of the neck ; b d represents the axis created hy incision. 

The operation, which is extremely simple, is thus performed. 
The patient being placed in position and Sims's speculum intro- 
duced, the cervix is seized and held firmly by a tenaculum. Then, 
by means of a pair of long-handled scissors, an incision is made 
as far as can be conveniently done without involving the vaginal 
junction, which will probably be as far as the point b in Fig. 138. 



Fig. 139. 



j* 



Sims's knife. 



The blade of Sims's knife, represented in Fig. 139, or of Emmet's," 
which is an improvement on it in having the blade move by a 



OBVIATING THE CONSEQUENCES OF FLEXION. 329 



ball-and-socket joint, is now introduced through the os internum, 
and the tissues are cut so as to lay open the posterior wall of the 
cervix. A little shoulder will, as Dr. Emmet has pointed out, be 
generally found to exist on the anterior wall of the canal. To 
this the blade of the knife should now be turned, and it should be 



cut through. 



Fig. 140 explains the operation. 



Fig. 140. 




Posterior section of the cervix. (Sims.) 



After the operation is thus completed a roll of cotton saturated 
with glycerine should, by means of the instrument represented in 
Fig. 75, be left in the canal, and a tampon of cotton be placed in 
the vagina to prevent hemorrhage, which sometimes follows. The 
patient should be kept in bed for a week or ten days, and once in 
twenty-four hours the dressing should be removed and the lips of 
the wound separated by the uterine sound, which should be gently 
passed into the cavity of the uterus on each occasion. "By this 
means the evils recorded as most frequently accompanying flexions 
may often be very markedly mitigated and sometimes entirely 
removed. 

Should an error be made, however, as to the etiology of the 
displacement, and this apparently trifling operation be performed 
during the existence of metritis, the gravest results may follow 
and the sufferings of the patient be greatly aggravated. Thus, a 
delicate and important point presenting itself for decision is 
whether existing metritis is the result or cause of the flexion. It 



330 FLEXIOXS OF THE UTERUS. 

may be either. If the cause, no operation should be undertaken 
until it be removed. If it be the result, the same statement holds 
true, but not so rigorously, for the metritis may disappear when 
the obstruction which has produced it is removed. 

Eetroflexiox. 

Definition and Frequency. — Eetroflexion is said to exist when 
the body of the uterus is bent towards the sacrum so as to create 
an angle on the posterior wall. In general practice it is by no 
means so frequent as anteflexion, but in women who have borne 
children it is much more common. Out of 339 cases of displace- 
ments recorded by M. IS'onat, 1 the following were the numbers of 
anterior and posterior inclinations : — 

Anteversion ......... 135 

Anteflexion 33 

Retroversion ......... 67 

Retroflexion ......... 14 

"While anteflexion is so frequent in the virgin state as to have 
been regarded as a physiological condition, retroflexion rarely 
occurs. 

Pathology. — Eetroflexion is most frequently the result of some 
influence which weakens the uterine walls, but, even when these 
are of normal strength, any directly applied force may overcome 
their resistance and produce a flexure. 

One reason why retroflexion is less frequent than anteflexion, 
is that the natural anterior obliquity of the uterus favors the 
latter, and opposes the former displacement. Another is un- 
questionably to be found in the fact that the former is more 
thoroughly guarded against by ligamentous support ; the round 
ligaments running as they do from the horns of the uterus to 
the vulva, decidedly tending to combat its occurrence, ^ot only 
do they do this ; the uterus being kept by them in anterior incli- 
nation, should softening of its structure occur, or any direct force 
be exerted upon it, naturally bends forwards. 

If this be so, it may be asked why metritis more generally 



Op. cit. 




EETEOFLEXION. 331 

results in retroflexion than in anteflexion. It Fi s- 141 . 

does so because the first effect of the increased 
uterine weight attending that disease is descen 
of the uterus. This relaxes the round liga- 
ments, tends to bring the uterine axis in coin- 
cidence with that of the middle of the pelvis, 
and favors retroflexion. Fig. 141 will explain 
this. 

. . . The uterus descending 

Varieties. — There are three varieties of re- changes its axis, 
troflexion : the first, second, and third degrees. 
In addition to these, the following peculiarities are noticed in dif- 
ferent cases : — 

In some the body is flexed backwards ; 
" " the neck is flexed backwards ; 
" " the neck and body are flexed backwards ; 
" " the body is flexed backwards and the neck forwards. 
Causes. — The special causes may be thus presented : — 
* Influences weakening uterine support. 
Inflammatory softening ; 
Parturition ; 
Pregnancy ; 
Fatty degeneration. 
Influences increasing uterine weight. 

Inflammatory enlargement ; 
Pregnancy ; 
Subinvolution ; 
Fibrous tumors. 
Influences pushing the fundus or cervix backwards. 
Abdominal or uterine tumors ; 
Distended bladder : 
Fecal masses above the fundus. 
Influences exerting traction backwards. 

False membranes. 
At the same time that all these causes must be admitted, it will 
generally be found that retroflexion is due to metritis, which has 
softened the parenchymatous tissue, and increased the weight of 
the body. 

Symptoms. — If the angle produced be sufficient to block up 
the uterine canal, dysmenorrhea and sterility will result. If it 



332 FLEXIONS OF THE UTERUS. 

be not so, there will be no symptoms except those attaching to 
the disorder which has produced the flexion. I should perhaps 
except uterine colic, a violent tenesmus of the uterus, due to 
imprisonment of mucus by the obstruction. 

Diagnosis. — This is made by these means : — 
Vaginal touch ; 
Conjoined manipulation; 
Rectal touch ; 
The uterine probe. 

The patient lying on the back, the index finger is introduced 
to the cervix, which is found in its normal place. It is then swept 
over the base of the bladder where nothing is observed. Then it is 
passed into the fornix vaginae, and here a round tumor continuous 
with the ridge of the cervix is discovered. The disengaged hand 
is then placed on the abdomen, and made to approximate the 
finger in the vagina, so as to grasp the body of the uterus. If 
the patient be thin, this will yield good results, but not otherwise. 
The index should now be carried into the rectum, iu order to 
study further the character of the tumor pressing upon this canal. 
The patient being then placed upon her side and the speculum 
introduced, the uterine probe, which has been curved in accord- 
ance with the picture impressed on the mind by the sense of 
touch, is gently passed into the uterine cavity to the fundus, 
which completes the diagnosis. 

Differentiation. — Retroflexion may be confounded with fecal 
impaction, fibrous tumors, cellulitis or peritonitis, and a prolapsed 
and enlarged ovary. The careful practice of the four diagnostic 
methods mentioned, will clear up all doubt. 

Treatment. — If the displacement should be simple and uncompli- 
cated, as will very rarely be the case, it will require treatment only 
in reference to obstruction to the ingress and egress of fluids. If 
it be a concomitant of any disease, this and not the symptomatic 
displacement should first receive attention. In many cases the 
displacement, although a result of metritis, reacts upon this con- 
dition, aggravating it and preventing, or, at least, retarding cure. 
Under these circumstances not only must the original affection 
receive attention ; its chief symptom should do so at the same time. 

In replacing the flexed part no great degree of difficulty is 
generally experienced. The patient being placed in the knee- 



TREATMENT. 



333 



elbow position, or upon the left side, two fingers of the right 
hand should be slid along the posterior vaginal wall until they 
reach the tumor felt pressing upon the rectum. Then the peri- 
neum being lifted so as to admit air into the vagina, the fundus 
is steadily pushed upwards to its place. This plan will almost 
always yield success. Should it not do so, Sims's speculum should 
be introduced, and the malposition rectified by two sponge-hold- 
ers. This method will very rarely fail. If it does so, Sims's 
repositor should be employed, as explained when treating of 
anteflexion. 



Fig. 142. 




Senttergood's pessary in position. (Peaslee.) 



334 FLEXIONS OF THE UTERUS. 

"When it is deemed advisable to sustain the flexed organ, all 
weight should be removed from the hips by a skirt supporter, 
tight dressing prohibited, and the patient cautioned against all 
muscular efforts. The abdominal walls, if lax, should be strength- 
ened by an abdominal supporter, and a well-adjusted pessary 
made to give direct support to the displaced part. A lever, ovoid, 
or horseshoe pessary, represented on page 317, may be tried in 
the hope that by them the difficulty may be rectified. Fig. 142 rep- 
resents the Scattergood pessary, one of the best which can be 
employed, in position. Cutter's pessary would likewise be appro- 
priate. 

In some cases packing the recto- uterine space with cotton or 
sponge will answer a better purpose than any other kind of sup- 
port, and in rebellious cases the stem pessary may be resorted 
to with proper precautions. The operation of slitting the cervix 
does not promise well in this displacement, for it is very com- 
monly attended by metritis, which contra-indicates that procedure. 

Lateroflexion. 

Sometimes the uterus is flexed to the right or left side as a 
consequence of inflammatory disease, increased weight, or direct 
pressure. This variety of displacement rarely proceeds to such 
a degree, however, as to result in obstruction of the uterine canal. 
Its chief importance is connected with diagnosis, for it may readily 
be mistaken for peri-uterine inflammation or a fibrous tumor. 
The practice of conjoined manipulation and the use of the uterine 
probe will generally settle the point. 

Treatment. — The treatment of lateroflexion should be conducted 
upon precisely the same principles which guide us in reference to 
anteflexion and retroflexion. 

Compound Flexions. — Besides the simple varieties of flexion 
mentioned, we meet with combinations of them. Thus we may 
find a uterus flexed forwards and laterally; backwards and for- 
wards ; backwards and laterally, fee. 

These varieties are known as — 

Ketro-anteflexion ; 
Eetro-lateroflexion ; 
Ante-retroflexion ; 
Latero-anteflexion, etc. 



LATEROFLEXION. 



335 



The student need not memorize these, but merely keeping in 
mind the fact that such combinations are possible, he will readily 
recognize them at the bedside, if he has mastered the three chief 
forms already treated of. 

The relative frequency of the varieties of displacements thus far 
treated of, may be estimated by examination of a comprehensive 
table presenting the experience of M. Nonat. 



Number of cases examined 
Anteversion 
Retroversion . 
Anteflexion 
Retroflexion 
Lateroflexion . 
Retro-anteflexion 
Prolapsus 
Retro-lateroflexion 
Retro-lateroversion 
Ante-retroflexion 
Lateroversion 
Latero-anteflexion 
Ante-lateroflexion 
Not specified 



339 



135 

67 
33 
14 

1 
10 
2 
1 
2 
2 
1 
4 
2 
65 



1 Op. cit., p. 416. 



CHAPTER XXIY. 



INVERSION OF THE UTERUS. 



Definition. — This dangerous and infrequent form of displace- 
ment consists in the turning of the uterus inside out. As the 
bottom of a bag may be pushed through its mouth, so that the 
inner surface becomes the outer, so may that of the uterus, and 
the occurrence of such an accident constitutes the disease which 
we are considering. 

Varieties. — Writers differ in classifying the varieties of the 
affection, some describing three and some four forms. For prac- 
tical purposes all these may be brought under two heads — partial 
and complete. In the first the body has become depressed, but 
has not passed through the os. In the second the uterus has 
been turned completely inside out, and the inverted fundus and 
body hang in the vagina or between the thighs, "velut scrotum" 



Fig. 143. 



Fig. 144. 




Partial inversion. 



Complete inversion. (Horteloup.) 



as it has been expressed by Hippocrates. Fig. 143 represents the 
first, and Fig. 144 the second form of the accident. 



PATHOLOGY — MECHANISM. 337 

In addition to these varieties the accident must be divided into 
acute and chronic, or sudden and gradual inversion, as it occurs 
rapidly or slowly. 

Normal Anatomy. — In treating of flexions of the uterus it was 
remarked that they are chiefly prevented by the resisting nature 
of the parenchyma of the cervix which supports the fundus and 
body. A similar function on the part of the entire uterine struc- 
ture keeps the cavities of the neck and body closed, and prevents 
inversion. Should that power, which in the pregnant uterus we 
call contractility, and in the non-pregnant, tone, be to any great 
degree impaired, the body of the organ, bereft of support, will 
incline to one side or the other. Should it be entirely abolished, 
the fundus under the influence of traction or downward pressure 
may pass through the unresisting os and escape into the vagina, 
constituting inversion. 

Pathology. — The accident evidently depends for its production 
upon two elements — 

1st. Relaxation and inertia of the uterine walls ; 
2d. Downward traction or pressure. 

The first of these may be a primary and original state, or it 
may be induced by the second after months of exhausting action. 
For example, after labor the uterine walls may remain lax and 
atonic from inherent inertia ; or their tissue in the non-pregnant 
state may be firm and resisting, yet in time be overcome by the 
traction and dilatation exerted by a large fibrous polypus attached 
to the fundus. 

Mechanism. — It is generally supposed that the part of the fun- 
dus which first undergoes inversion is the middle. This is 
denied by Kiwisch who maintains that one horn first inverts itself 
and is followed by the fundus, the other horn, and then the entire 
body. I have met with one case which proves incontestably that, 
even if this is not a rule, inversion at least occurs in this manner 
sometimes. A patient who for several years had suffered from 
menorrhagia applied to Prof. G. A. Budd, of this city, for treatment. 
Upon examination he discovered what he supposed to be a fibrous 
polypus equal in size to a hen's egg attached to the uterine cavity 
near the entrance of the right Fallopian tube. Carefully differ- 
entiating this, as he supposed, from partial inversion, he applied 
the ecraseur and removed it, when he discovered that he had 
22 



338 INVERSION OF THE UTERUS. 

removed one horn of the uterus with a part of the corresponding- 
Fallopian tube and round ligament. The case, which was one of 
incipient inversion, was not susceptible of diagnosis. The monor- 
rhagia attending it was entirely relieved by the operation, the 
patient rapidly recovering. 

When the accident begins in this way, the inverted horn pulls 
down the other parts, with greater or less rapidity, and thus 
the method of occurrence may be lost sight of. Eokitansky, in 
speaking of irregular post-partum uterine contraction, thus de- 
scribes partial inversion, with which he has twice met : " We 
must here mention a very singular circumstance which may, on 
account of the consequent danger, become important, and may 
even be misunderstood in post-mortem examinations ; it is para- 
lysis of the placental portion of the uterus occurring at the same 
time that the surrounding parts go through the ordinary processes 
of reduction. It induces a very peculiar appearance. The part 
which gave attachment to the placenta is forced into the cavity 
of the uterus by the contraction of the surrounding tissue, so as 
to project in the shape of a conical tumor, and a slight indentation 
is noticed at the corresponding point of the external uterine sur- 
face. The close resemblance of the paralyzed segment of the 
uterus to a fibrous polypus may easily induce a mistake in the 
diagnosis, and nothing but a minute examination of the tissue 
can solve the question. The affection always causes hemorrhage, 
which lasts for several weeks after childbirth, and proves fatal by 
the consequent exhaustion." 

Causes. — Anything which produces distension and relaxation of 
the tissue of the uterus prepares the way for inversion so com- 
pletely that a very trifling exciting cause may produce it. For 
example, any decided traction or pressure exerted upon the fun- 
dus of a uterus thus affected even to a limited degree may directly 
result in it. (Fig. 145.) These influences when combined are 
evidently sufficient for the induction of the accident, and it is 
generally to a union of the two that it is due. The question now 
arises whether either of them alone can cause it. With refer- 
ence to the efficiency of the first element, the answer may be affir- 
mative, since with complete relaxation inversion may occur from 
a very insignificant exciting cause, as coughing, sneezing, or a 
change of posture. But as to the possibility of any amount of 



CAUSES. 



339 



force inverting the non-pregnant and undilated uterus there is 
much doubt. At first thought every one will feel inclined to 

Fig. 145. 




Uterus inverted by a fibroid attached to fundus. (McClintock.) 



express a decidedly negative opinion, but the evidence on record 
in favor of such a possibility is too strong to be entirely ignored. 
A portion of it is therefore laid before the reader. 

Puzos, 1 in 1744, read before the Academy of Medicine of Paris 
a memoir in which he declared that he had seen the accident in 
women who had never borne children. Boyer 2 cites a similar 
example in a female whose uterus contained no foreign body, and 
Daillez 3 tells us that Baudelocque met with a case in a girl fifteen 
years of age in whom clandestine delivery could not have occurred, 
since a perfect hymen existed. 

Prof. "Willard Parker, of New York, places at my disposal the 
following case. A young woman who had borne one child, seven 



1 Colombat on Females. Meigs, p. 1S2. 

2 TraitS des Mai. Chirurgioales. 

3 Colombat, op. oit. 



340 INVERSION OF THE UTERUS. 

or eight years previously, but had never had any recognized 
uterine disease, while making a violent effort in rolling tenpins, 
suddenly felt something give way within her, after which she suf- 
fered the most intense pain and became completely disabled. Dr. 
Parker being called to see her, after a hasty examination coincided 
with the opinion of the attending physician, that a polypus had 
been suddenly expelled and was hanging in the vagina. Impressed 
with this belief he removed the whole mass, when, to his surprise, 
he found that he held in his hands the inverted uterus with its 
tubes and ligaments. The patient recovered without any bad 
symptoms. 

It is impossible to admit the occurrence of inversion in an 
undilated uterus, and probably in all these cases some distending 
influence which escaped observation preceded the accident. The 
suggestion of Colombat is certainly very plausible, that hydro- 
metra, physometra, or retention of the menses must, in such cases, 
have produced dilatation, which being followed by pressure just 
after the escape of the contained air or fluid, gave rise to the 
displacement. 

Inversion generally follows parturition, but there are other 
causes for it, which may be thus tabulated : — 

Influences producing inversion through uterine distension and atony. 

Pregnancy ; 

Hydrometra ; 

Physometra ; 

Tumors ; 

Polypi ; 

Hydatids ; 

Inertia uteri; 

Eetained menses. 
Influences producing inversion by exertion of pressure or traction. 

Traction on placenta ; 

Traction by polypi or tumors ; 

Sudden delivery of child by traction ; 

Muscular efforts. 
Instances of its production by all these causes are on record, 
though the greatest number of cases have followed parturition. 
Of 400 cases collated by Dr. Crosse, of Norwich, England, 350 
followed delivery, and of the remaining 50, forty were due to 
polypi. This disproportionate frequency does not, however, 



SYMPTOMS. 



341 



invalidate the fact that the other causes mentioned have resulted, 
and may result in the accident. Most frequently it occurs very 
soon after delivery, though Ane and Baudelocque report its 
having taken place on the third, and Leblanc on the tenth day. 

Symptoms. — Should inversion occur suddenly, as for instance 
after delivery, the patient will complain of discomfort about the 
vulva, faintness, and nervous disturbance. Hemorrhage and 
tendency to collapse will show themselves, and unless proper 
treatment be adopted at an early period, death may ensue. A 
physical examination will at once settle the diagnosis, for a large 
flabby, globular mass, perhaps with the placenta attached to it, 
will be found in the vagina, if the condition be incomplete, or 
between the thighs of the patient if it be complete. But very 
often no diagnosis will have been made at the time of its occur- 
rence, and months, perhaps years, afterwards the physician will 
be called upon to determine the character of the case, which will 
probably present the following symptoms : — 

Occasional or constant hemorrhage ; 

Dragging pains in back and loins ; 

Difficulty in locomotion ; 

Difficulty in defecation and micturition ; 

Chlorosis and its accompanying evils. 
Physical Signs. — All these symptoms belong as much to poly- 
pus, fibrous tumor, and cancer as to inversion, and to determine 



Fig. 146. 



Fig. 147. 





Polypus. 



Inversion. 



34.2 



INVERSION OF THE UTERUS. 



their true cause physical exploration is indispensable. Should 
the inversion be complete, the finger being introduced into the 
vagina will meet with a tumor which the examiner will at once 
know is either the displaced body of the uterus or a polypus, and 
his attention will be directed to their differentiation. 



IF IT BE A POLYPUS, 

The probe will pass by its side into 
the uterus ; 

Conjoined manipulation will reveal 
the uterine body ; 

Rectal touch will reveal the uterus ; 

Recto-vesical exploration will reveal 
the uterus ; 

Pedicle will be small. 



IF IT BE INVERSION, 

The probe will be arrested at the 
neck ; 

Conjoined manipulation will reveal a 
ring where the uterine body should be ; 

Rectal touch will not reveal the uterus ; 

Recto-vesical exploration will not re- 
veal the uterus ; 

Pedicle will be large. 



Should the inversion be incomplete, diagnosis will always prove 
difficult, and in fat women often impossible. It will depend upon 
the following signs : — 



Fig. 148. 



Fig. 149. 





Sessile fibroid. 



Part'al inversion. 



IF IT BE A FIBROID, 

The probe will show increase of uterine 
cavity ; 

Conjoined manipulation will reveal 
body of uterus ; 

It will have come on gradually ; 

It will have no reference to parturition. 



IF IT BE PARTIAL INVERSION, 

The probe will show diminution of ute- 
rine cavity; 

Conjoined manipulation will reveal 
small abdominal ring ; 

It will have occurred suddenly ; 

It usually follows parturition. 



Course, Duration, and Termination. — All these are very variable. 
The accident occurring after delivery may rapidly, unless relieved, 



METHODS OF REPLACING THE UTERUS. 343 

produce death from hemorrhage and exhaustion ; or it may con- 
tinue for many years, giving very little annoyance ; or, again, it 
may render the life of the patient miserable on account of hemor- 
rhage and other attending symptoms, and nevertheless last for 
years. As a rule it may be stated that inversion continues unless 
relieved by treatment, and yet even this is not without exception. 
The womb has been known under these circumstances to replace 
itself by its own contractions when the accident occurs after labor. 
Prof. Meigs 1 minutely reports an instance where such spontaneous 
reposition took place more than two years after the occurrence of 
the accident. Even admitting these and other cases, spontaneous 
reduction must be regarded only as a curiosity, and not as a pro- 
cess to be anticipated. 

Prognosis. — This will be governed by the strength of the patient 
and the possibility of returning the organ to its place. Should 
the immediate danger arising from hemorrhage and collapse pass 
off, the prognosis is generally good. When the prospect of re- 
turning the uterus seems brightest, however, the practitioner is 
sometimes disappointed by the existence of adhesions. Thus 
Velpeau, 2 after the removal of a polypus attached to an inverted 
uterus, was completely foiled in restoring it, and the patient died 
from peritonitis. 

Treatment. — There are three plans of treatment : — 

1. To return the uterus to its place; 

2. To leave it displaced and adopt means preventive of hemor- 
rhage ; 

3. To remove it by amputation. 

Methods of Replacing the Uterus. — In cases of sudden inversion 
the accident should be relieved as soon as possible, for experience 
has shown that the longer the interval between the occurrence and 
the adoption of means for reduction, the greater the difficulties 
attending its accomplishment. Should the placenta or a large 
tumor be attached to the body, the propriety of its removal must 
be at once considered. If this should appear easy, the patient's 
strength be good, and no appearance of hemorrhage exist, it 
should be removed as rapidly as possible. But should the oppo- 
site conditions prevail, it would be wiser to insure the woman 

1 Colouibat, op. cit., p. 187. ~ Beequerel, p. 306. 



344 INVERSION OF THE UTERUS. 

against immediate peril and deal with the complication after she 
has rallied. 

The hands being dipped in warm water and thoroughly oiled, 
the mass, if external to the body, should be grasped in both 
palms and one of two methods of reduction essayed. The uterine 
body should be indented so as to push up first the part which 
first escaped, or the whole body should be pressed upwards so as 
to re-invert the pedicle of the mass and thus return the fundus 
last. The first procedure will be favored by relaxation of the 
organ ; the second by contraction, and the operator should bear 
this fact in mind during his manipulations. Should tetanic spasm 
of the uterine fibres exist, so as to resist replacement, an anaesthetic 
should be employed without delay. 

Until the fact was demonstrated by Dr. Tyler Smith, of London, 
that, even after the continuance of inversion for years, reduction 
is possible, the second and third plans of treatment were the only 
resources at the command of the physician in cases of long standing. 

In April, 1858, Dr. Smith reported a case of twelve years' 
standing reduced by him ; and in July of the same year Prof. 
White, of Buffalo, N. Y., succeeded in replacing one which had 
been inverted for sixteen years. Since that time many success- 
ful cases have been published, among others one of thirteen years' 
standing, by Dr. Noeggerath, of K. Y. Dr. Smith advised mani- 
pulation followed by gradual pressure from an air bag in the vagina, 
while Dr. White succeeded by manipulation, and pressure by 
means of a large bougie. The first plan occupied eight days, and 
the patient recovered ; the second fifty minutes, and the patient 
died of peritonitis. 

The diagnosis having been clearly made and reduction deter- 
mined upon, the bowels and bladder should be emptied, and the 
patient put under the influence of an anaesthetic, and laid on 
her back upon a strong table. The operator should always be 
attended by three or four reliable counsellors, upon whom he 
may call not only for advice but physical aid. As Prof. Geo. T. 
Elliot has pointed out, the strength of one man will often fail to 
accomplish what that of several, replacing each other in rapid 
succession will readily effect. Having thoroughly oiled one hand, 
the nails of which have been pared, he should now slowly dilate 
the vagina so as to introduce it, and grasp in its palm the entire 



METHODS OF REPLACING THE UTERUS. 



345 



tumor. The other hand should be laid upon the abdomen so 
as to press just over the ring, which marks the non-inverted 

Fig. 150. 




Reducing an inverted uterus. (Sims.) 



cervix, and oppose the force exerted through the 
vagina, so as to prevent too great stretching of this 
canal. 

In a case of four years' standing, which I attended 
with Dr. Joseph Worster, of this city, and which 
had been subjected to eight previous attempts? 
each varying in duration from two to three hours' 
I suggested substituting for the hand a cone of 
boxwood four inches long. The patient being very 
thin, this could readily be inserted into the ab- 
dominal ring of the uterus, and it was gradually 
forced down into the inverted fundus for such a 
distance'as to dilate the cervix and allow reposition. 
Fig. 151 represents the shape of the boxwood plug 
employed. 

In replacing the non-pregnant uterus three methods 
of manipulation may be tried in succession : — 

1. The method of Viardel, dilating by the fingers 
the constricting neck and forcing up first the tissue 
which came forth last. 



Fig. 



• making 
-pressure 
sion. 



346 INVERSION OF THE UTERUS. 

2. The method of White, of Buffalo, by indenting the fundus 
and thus returning, first, the part which first escaped. 

3. The method of Noeggerath, by indenting the cornua, by 
pressure over the lateral surfaces of the tumor so as to re-invert 
one or both of these parts, thus imitating the occurrence of the 
accident, according to the theory of Kiwisch. 

One after the other each of these plans should be tried, the 
operator not persevering too long, but yielding his place to 
another as soon as his hand becomes fatigued or benumbed. 

It is impossible to put an absolute limit to the time which 
should be allotted to one attempt, but these efforts cannot be per- 
sisted in much longer than two hours without great danger from 
metritis, cellulitis, or peritonitis. It is true that numbers of suc- 
cessful cases are on record in which from three to five hours have 
been spent in continuous exertion before success was accomplished 
and in which no unfavorable symptoms have arisen ; but a safer 
and more judicious course would be to desist after a reasonable 
effort, secure what has been gained by pressure from a caoutchouc 
bag in the vagina, administer a large dose of opium, and make 
another attempt in thirty-six or forty-eight hours. Manipulation 
should then be cautiously repeated for about the same period, 
and again, in case of failure, followed by the air bag. Should no 
signs of inflammation show themselves, there could be no valid 
objection to extending this plan of treatment, over a period of 
time indefinitely long. With the facts now before us we are 
warranted in asserting that henceforth it will limit the operation 
of amputation to the small number of cases in which the condition 
of the patient is such as to render delay and manipulation alike 
impracticable. 

The resistance offered to the return of the fundus is generally, 
not in the vaginal portion of the neck, which remains in normal 
position, but in that which is inverted and undergoes a certain 
amount of atrophy that diminishes its calibre. Should it be 
recognized that resistance is due to constriction exerted by the 
fibres of the vaginal cervix, a pair of long, blunt-pointed scissors 
should be carried up upon the fingers and these fibres snipped at 
two or three points. Then the efforts at manipulation should be 
renewed. 



m^^^mi^mm 



METHODS OF CHECKING HEMORRHAGE. 347 

Methods of Checking Hemorrhage, the Uterus being left in Situ. — 
Should the operator fail in repeated attempts at reduction, it be- 
comes a question whether he should amputate the displaced organ 
or leave it in its abnormal position and endeavor to combat the 
evils resulting. The greatest of these is unquestionably hemor- 
rhage, which steadily exhausts the patient ; but others of less 
moment arise from dragging of the uterus upon its ligaments and 
the mechanical inconvenience of a tumor in the vagina. If the 
patient be near the menopause, both of these may diminish by 
atrophy and cessation of menstruation. Should she be young, 
artificial means may, in a limited degree, accomplish the same 
results. 

The most vascular growths, such, for example, as haemorrhoids 
and nsevi, may be diminished in size and rendered non-hemor- 
rhagic by astringents or caustics, which destroy their superficial 
varicose vessels and leave a more healthy tissue beneath. The 
inverted uterus may be similarly acted upon, not only in checking 
hemorrhage, but in producing atrophy, and thus removing, to a 
certain extent, the two sources of suffering. 

Solutions of alum, tannin, persulphate of iron, or acetate of 
lead may with advantage be injected into the vagina so as to bathe 
the uterus freely, or they may be placed in contact with it by 
means of pledgets of cotton. Should these fail in checking the 
flow, a plan, proposed by Aran, of applying caustics to the whole 
bleeding surface may be resorted to. The tumor being drawn 
down and exposed to view as much as possible, its surface is seared 
by the actual cautery or touched by potassa cum calce or the 
mineral acids. The organ, after being bathed in a neutralizing 
fluid, is then enveloped in lint, so as to protect the vaginal walls, 
and placed within the pelvis. I have never seen the method 
employed, but would not hesitate in an appropriate case to venture 
upon it. Aran declares that not only is hemorrhage checked by it, 
but great diminution of the tumor effected. The procedure re- 
commends itself as eminently rational, and when it is remembered 
that the only other alternative is amputation, the propriety of 
giving it consideration must be admitted. 

Many cases are on record in which the uterine mucous mem- 
brane has become altered so as to resemble skin, and in which the 
patients have lived without suffering for many years. Dr. Alex- 



348 "INVERSION OF THE UTEEUS. 

ander H. Stevens has had one under observation for more than 
thirty years ; Dr. Charles A. Lee diagnosticated one which had 
remained undetected for twenty- five years ; and the works of older 
writers offer many other examples. If we can bring about a simi- 
lar condition by artificial means and avoid the operation of ablation, 
we will certainly be acting in the best interests of the patient. It 
is for this purpose that cauterization offers itself as a resource. 

Methods of Amputating. — Although it cannot be denied that 
instances may present themselves in which, from impossibility of 
returning the inverted uterus, removal of the whole organ is 
indicated, it is equally undeniable that the operation has been 
resorted to very often upon insufficient grounds and before efforts 
at reduction had been fairly tried. Dr. Smith succeeded after 
persevering for eight days, and Dr. Emmet, in one instance, 
labored incessantly for four hours, when success crowned his 
efforts. In the hands of many practitioners both these cases 
would have been treated by amputation before success was at- 
tained. Amputation of the inverted uterus will probably be less 
frequently performed in the future than it has been in the past. 
It is destined to assume among operative procedures its proper* 
place as a last resort. In addition to its own manifest and in- 
herent dangers it must ever present these great objections: — 

1st. Hernia of the abdominal or pelvic viscera may take place 
into the inverted sac and cannot be detected ; 

2d. It necessarily produces emansio-mensium and its train of 
evils ; 

3d. It induces sterility. 

It is impossible to conceive of circumstances which would 
justify the procedure before full consultation with the most able 
counsel attainable. 

Eemoval of the uterus, although attended by great danger, 
often ends in recovery. Eadford, J. C. Clarke, 1 and others have 
reported cases in which an inverted uterus has sloughed off from 
strangulation without a fatal issue, and Osiander for many years 
showed a patient in his lecture-room from whom, after delivery, the 
midwife tore away not only the placenta but the inverted uterus 
to which it was attached. The most comprehensive view of the 
results of amputation is presented us by Dr. West in the following 
table : — 

1 Dublin Journal, 1837. 



METHODS OF AMPUTATION". 349 

Operation 
Kecovered. Died, abandoned. 
Uterus removed by ligature ... 45 33 10 2 

" " " knife or ecraseur .5 3 2 

" " " kriife or ecraseur 

preceded by the ligature . 9 6 3 

59 42 15 2 

Four methods of amputation have been employed ; by the 
knife, the ligature, the ecraseur, and a combination of the liga- 
ture with either of the others. The ligature is objectionable 
because it is slow in action, leaves a putrefying mass for a long 
time in conteict with the vaginal walls, and exposes to peri- 
tonitis. The use of the knife exposes to the danger of hemor- 
rhage. No other means compares with the ecraseur, which in 
great degree prevents hemorrhage at the same time that it is rapid 
and certain in its action. In applying its chain around the upper 
portion of the tumor, the organ should be drawn down as far as 
possible through the vulva. 

If amputation becomes necessary soon after delivery, when 
great vascularity exists, the ligature may be applied for 36 or 48 
hours, after the plan pursued by Dr. McClintock, of Dublin, and 
then the ecraseur resorted to. 

Should the stump remaining, after removal by any method, 
show signs of hemorrhage, the white-hot iron should be passed 
over its surface through the speculum. A tampon should be 
avoided, for fear that blood collecting above it might separate 
the lips of the wound and enter the peritoneal cavity. 



CHAPTEE XXV. 



PERI-UTERINE CELLULITIS. 



History. — The history of this affection presents* one of those 
examples, which are often repeated in medical literature, of a 
subject which was once understood being subsequently com- 
pletely overlooked and forgotten. 

There can be little doubt that it is to this disease that allusion 
was made by Archigenes, who flourished in the second century, 
and whose account of it was subsequently repeated by Oribasius 
in the fourth, and Aetius and Paul of xEgina in the sixth and 
seventh. The last two unquestionably refer to it under the head 
of "Abscess of the Womb," for in one passage Paulus especially 
speaks of cases in which the " aposteme is seated about the mouth 
of the uterus." 

The modern history of the subject may be thus stated: — 
Described by Eichard Wiseman, 1 England, as " Distempers of 
the uterus in childbed," 1679. 

" Xichs. Puzos, 2 France, " Depots Laiteux," 1743. 
" Bourdon, a pupil of Eecamier, "Fluctuating 
tumor of true pelvis," 1841. 

" Doherty, Ireland, " Chronic inflammation of the 
appendages of uterus," 1843. 

" Marchal de Calvi, " Intra-pelvic-phlegmonous 
abscess," 1844. 

" Churchill, 3 Ireland, as " Abscess of uterine ap- 
pendages," 1844. 
" " Lever, England, 1844. 

1 McClintock, "Diseases of Woman," p. 1. 

2 Drs. West and McClintock date the appearance of Puzos, " Traite d'Accouche- 
ment," 1759. They are probably in error, as Bernutz and Nonat both date it 1743. 

3 West, " Diseases of Women," Am. ed., p. 310. 



NORMAL ANATOMY. 351 

It will thus be seen that after being appreciated, then entirely 
forgotten, then for a second time signalized, the knowledge of 
this affection languished for nearly two centuries, suddenly to be 
restored by the efforts of four investigators who entered the field 
almost simultaneously. It would be unjust to a conscientious 
observer, M. Auguste Nonat, not to mention the great influence 
which his writings have had in advancing our knowledge, but 
when he commenced his investigations in Hopital Cochin, in 
1846, the morbid state which he subsequently did so much to 
elucidate, had already received considerable attention in Great 
Britain. 

Definition, Synonymes, and Frequency. — It has been described 
by different writers under the following titles, peri-metritis, peri- 
uterine phlegmon, inflammation of the broad ligaments, pelvic 
abscess, and pelvic cellulitis. The last term, which was applied 
to it by Sir James Simpson, graphically describes the nature and 
seat of the disease ; but it is open to the grave objection of being 
too general in its application, and not sufficiently confining within 
proper limits a truly classic affection. 

Normal Anatomy. — " The sub-peritoneal pelvic tissue," says Dr. 
Savage, in his beautiful work entitled "Illustrations of the Female 
Pelvic Organs," "fills up all that part of the pelvic cavity between 
the pelvic 'roof and floor of the pelvis, which is not occupied 
by the viscera, and is the sole bond of union between them." 
Any one can satisfy himself as to the abundance of loose cellular 
tissue in the pelvis, by even a rough dissection. It will be found 
in the broad ligaments in great abundance, separating their con- 
tents, between the vagina and rectum, the rectum and sacrum, the 
uterus and bladder, the bladder and abdominal parietes, and in- 
vesting the psoas and iliac muscles. The relations of the urethra 
and rectum to this tissue are peculiar, each being isolated in a 
sheath or canal which may be removed with ease. 1 

Everywhere around the pelvic organs cellular tissue exists 
except between the peritoneum and uterus. Here so little is dis- 
coverable" that some have ventured to deny its existence, while 
all admit that over the body of the organ it is difficult of demon- 
stration. Dr. Farre 2 declares that along the median line and over 

1 Savage, op. cit. 2 Cyc. Anat. and Phys.. Sup., p. 631. 



352 PERI-UTERINE CELLULITIS. 

the whole fundus he has found the peritoneum inseparable from 
the uterus, except after prolonged maceration. On the sides of 
the organ, and at the cervix the connection is not so intimate, loose 
cellular tissue existing at these points to such an extent as to 
permit of gliding the investing membrane upon the uterus. M. 
Goupil, 1 who has made a special study of this tissue, declares that 
it is so small in amount at the point of contact of the peritoneum 
and vagina, and in front and rear of the uterus, that " its presence 
can scarcely be determined." 

Pathology. — According to the wide range given to the affection 
by the majority of English pathologists, this tissue is the seat of 
the disease under consideration, which may affect any or all of its 
parts. Drs. West, Simpson, and most British writers, except Dr. 
Bennet, adopt this view and regard as instances of the affection 
any inflammation of the cellular tissue within the pelvis. But 
this evidently leads to great confusion. It is certainly not con- 
ducive to clearness of comprehension to blend the description of 
iliac, psoas, and peri-rectal abscesses with this disease. 

French writers, 2 on the contrary, regard as instances of peri- 
uterine cellulitis only inflammation of the cellular tissue of the 
broad ligaments and of that immediately in contact with the 
uterus at its junction with the vagina and bladder. While ad- 
mitting that inflammation originating here may affect, by con- 
tinuity of structure, other areolar tracts in the pelvis, they regard 
these as complications, designating them by different appellations, 
and do not admit them as elements of this affection. This is the 
definition which I would adopt, and to express it clearly have 
employed the term peri-uterine, in place of pelvic, cellulitis. 

Peri-uterine cellulitis has three stages ; 1st, the stage of active 
congestion ; 2d, that of effusion of liquor sanguinis ; 3d, that of 
suppuration. In its course it may be likened .to an ordinary 
furuncle ; at first there is simple congestion accompanied by pain, 
heat, and swelling ; then liquor sanguinis is effused, which 
creates hardness and tension, and lastly suppuration occurs, and 
ends the morbid process, unless one of two other terminations 
takes place. Eesolution may occur, or, in place of suppuration, 
the areolar tissue involved may be destroyed, as it so generally 

1 Becquerel, p. 441, vol. i. * Aran, Mai. de l'Uterus, p. 675. 



PATHOLOGY. 353 

is in anthrax and phlegmonous erysipelas, and come forth as a 
sloughing mass. 

The term phlegmon, now almost obsolete with us, but still in 
use on the continent of Europe, which signifies inflammation of 
areolar tissue, is strictly applicable to this affection. Its course 
is similar to that of areolar inflammations in other parts of the 
body, and its three stages are identical with theirs. 

The usual, indeed the almost invariable, seat of peri-uterine 
cellulitis is the areolar tissue of the broad ligaments and gene- 
rally that of one side only is affected. 

In a certain number of cases where no affection of the areolar 
tissue of the broad ligaments exists, circumscribed tumors, in 
immediate contact with the womb, have long been noticed. Lis- 
franc supposed them to be due to partial parenchymatous metritis, 
" engorgements," which had resulted in enlargement of one part 
of the organ, and no one contradicted him until M. Konat, 1 about 
the year 1849, described them as being due to phlegmonous in- 
flammation in the areolar tissue immediately around the uterus, 
i. e.-, between the cervix and rectum, the cervix and bladder, and 
immediately by the side of the neck. The existence of this 
variety of cellulitis has been denied by M. Bernutz, who sustains 
his position by abundant proof. In reference to it, I will merely 
say here, that there are, so far as my knowledge extends, only two 
cases of such limited cellulitis substantiated by autopsic evidence, 
one reported by M. Demarquay, 2 the other by M. Simon. 3 There 
are many in which abscesses in the broad ligaments have pointed 
anteriorly or posteriorly to the cervix, but these come within a 
different category. The broad ligaments and their entire contents, 
cell alar tissue, ovaries, and Fallopian tubes, are more frequently 
affected than any other parts, and M. Aran goes so far as to say 
that the collections of pus occurring in pelvic cellulitis " belong- 
more particularly to the ovaries and tubes." In post-mortem 
examinations these parts are often found imbedded in a mass of 
effused material, the ovaries, one or both, in a state of suppuration, 
and the tubes inflamed and filled with pas, or constricted at uterine 
and ovarian extremities and dilated by sero-purulent material so 

1 Op. cit., p. 237. 2 Gazette des Hopitaux, April 17. 1S5S. 

3 Bull, de la Soc. Anat. de Paris. 

23 



354 



PEKI-UTEKINE CELLULITIS. 



. OF CASES. 
1 


AUTHORITY. 

M. Nonat. 


2 


M. Nonat. 


3 

4 


M. Nonat. 
M. Nonat. 



as to constitute tubal dropsy. I have examined the post-mortem 
reports of cases by a number of authorities with reference to 
this point, and rejecting only those in which the examination was 
made in too careless a manner to allow of their admission, I pre- 
sent them in the following table : — 

SEAT OF PURULENT COLLECTION. 

Behind the uterus connecting with suppurating 
cyst in left ovary; small abscess in right ovary. 

Between uterus and rectum extending into broad 
ligaments of both sides. 

On left side extending from uterus to ilium. 

Behind uterus and vagina extending into left 
broad ligament ; another the size of a hen's egg 
just behind the uterus, opening into a third, 
very large, extending to Sigmoid flexure and 
into broad ligament. 

Left broad ligament. 

Opposite right sacro-iliac synchondrosis under 
psoas muscle, another to the left of and behind 
the rectum. 

Left broad ligament. 

Left broad ligament. 

In cellular tissue between uterus and rectum and 
also in recto-uterine pouch of peritoneum. 

Size of little orange between the bladder and 
uterus sending conoidal prolongation into left 
broad ligament. Its limits were as follows : 
base of bladder in front ; neck and body of 
uterus behind ; peritoneum above ; vagina 
below : at the sides it ran off into the broad 
ligaments. 

Left broad ligament. " 

Left ovary, right tube, with pelvic adhesions 
throughout. 

Size of apple in left broad ligament. 

At side of uterus and in the left broad ligament. 

It will thus be seen that of this number, which is large when it 
is remembered that the disease rarely ends in death, but two 
cases present instances of cellulitis, uncomplicated by disease of 
the cellular tissue of the broad ligaments, ovaries, or tubes. One 
of these, that of Simon, is conclusive of the possibility of such 
disease ; that of Demarquay is doubtful, for with the abscess in 
the cellular tissue, there was also one in the cul-de-sac of Dou- 
glas. The purulent collections in this disease may be results of 



Dr. West. 
Dr. West. 



Dr. West. 

Dr. McClintock. 

M. Demarquay. 



10 



M. Simon. 



11 


M. Aran. 


12 


M. Aran. 


13 


M. Bourdon 


14 


M. Aran. 



morbid action in the cellular tissue, the ovaries, or the Fallopian 
tubes. In other words, with the disease known as cellulitis we 
often, indeed generally, have other affections, some of them, in 
the present state of our knowledge, not separable from it, which 
attend upon it as complications. 

Complications. — The complications of peri-uterine cellulitis 
are — 

Pelvic peritonitis; 

Ovaritis; 

Fallopian salpingitis ;* 

Endometritis. 
The occurrence of these complications with cellulitis is so fre- 
quent that they may, at least the first three, almost be regarded as 
elements of it, when it exists in severity. They are indeed univer- 
sally present where the tissue of the broad ligaments is seriously 
involved, as will be seen by reference to autopsic evidence con- 
tained in any of the works upon the subject. The fact of the 
frequent co-existence of endometritis should be especially noted, 
for great injury may be done by local treatment of it, under the 
supposition that it is the cause of symptoms which in reality are 
the results of cellulitis. 

Course, Duration, and Termination. — It is necessary that I should 
here inform the reader that the account which I shall give of this 
part of our subject will differ essentially from that generally given 
in systematic works, for the reason that, regarding pelvic cellu- 
litis and pelvic peritonitis as different affections which are usu- 
ally treated of synonymously, I shall attempt to describe them 
separately. Cellulitis proper, that is, uncomplicated by other 
diseases, rarely passes into a chronic state, but usually in the 
course of two or three weeks passes off by resolution or ends in 
suppuration. Any one of its usual complications, however, peri- 
tonitis, endometritis, ovaritis, or salpingitis, may pass into that 
condition and thus leave the impression upon the mind of the 
observer that the original affection has done so. Or one or more 
abscesses may discharge themselves by long sinuses which fail 
to allow of their complete evacuation, and may continue to pour 
out pus for months or even years. In saying that cellulitis rarely 

1 <ra^irty^ " a tube." 



356 PERI-UTERINE CELLULITIS. 

becomes chronic, I look upon chronic pelvic abscesses rather 
as one of its results than one of its stages. If the case be of 
acute character and occur as a sequel of parturition, suppura- 
tion may take place in a few days, but ordinarily, even under 
these circumstances, it does not occur for two or three weeks. In 
a chronic case the effused matter may remain hard, resisting, and 
ligneous, for months, without showing signs of softening, but 
such instances are exceptions to the rule. After suppuration has 
occurred the disease may follow one of three courses. 

1st. The accumulated pus may discharge itself and the abscess 
gradually dry up and disappear. 

2d. The empty sac, lined by pyogenic membrane, may for an 
unlimited time go on pouring out pus. 

3d. Small abscesses may form and discharge in one part, then 
others may do so in another, until the whole pelvic areolar tissue 
is perforated by them and by fistulous tracts connecting them. 

There are various outlets for the imprisoned purulent accumu- 
lation : — 

1st. Through the abdominal walls or saphenous openings ; 

2d. Through the pelvic viscera, bladder, rectum, vagina, ure- 
thra, or uterus ; 

3d. Through the floor of the pelvis near the anus ; 

4th. Through the pelvic foramina, obturator, or sacro-ischiatic ; 

5th. Through the pelvic roof into the peritoneal cavity. 

Sometimes the purulent collection burrows into the surround- 
ing tissues and evacuates itself at a distance. In one case which 
I saw with Dr. Echeverria, it passed through the sciatic foramen, 
and burrowing upwards and forwards, came forth near the great 
trochanter. It may thus take so eccentric a course as to mislead 
the practitioner as to the seat of the abscess. 

The most frequent channels of evacuation are the vagina and 
rectum, in the non-puerperal form, and probably the abdominal 
walls in the puerperal, or at least the results of Dr. McClintock's 1 
carefully noted cases would lead us to believe so. In 37 puer- 
peral cases treated by him which ended in suppuration, 20 
abscesses discharged in the iliac regions, 2 above the pubes, 1 in 
the inguinal region, and 1 beside the anus. Of the remaining 

1 Op. cit. 



PROGNOSIS — CAUSES. 357 

13, 6 were discharged per vaginam, 5 per anum, and 2 burst 
into the bladder. In the non-puerperal variety it is extremely 
rare for the abscess to discharge externally, and fortunately in 
both forms it is rare for it to burst into the peritoneum. 

Prognosis. — A guarded prognosis should always be made as to 
the time of recovery, for no amount of experience can foresee the 
course of the affection ; whether the effused liquor sanguinis will 
disappear by absorption in three weeks ; whether the discharge 
of one abscess will end the patient's suffering ; or whether a chronic 
induration will exist for a great length of time. But fortunately 
it may be stated, that the prospects as to life, are decidedly 
favorable, though in cases occurring just after parturition, there 
is always some danger from general peritonitis. 

Causes. — The disease usually occurs as a result of one of the 
following causes : — 

Parturition or abortion ; 

Inflammation of uterus or ovaries ; 

Direct injury from coition, caustics, pessaries, operations, or 
blows. 

Parturition or abortion produces, according to statistics, from 
one-half to two-thirds of all the cases. Even this large propor- 
tion I believe to fall short of the truth, from the fact that those 
collecting the statistics from which the deductions were drawn, 
made no distinction between this disease and pelvic peritonitis. 
Cellulitis will very rarely be met with except after the parturient 
process. It is true that when the puerperal state exists as a 
predisposing cause, exposure to cold, fatigue, over-exertion, &c, 
will excite it; but under these circumstances they are merely 
immediate and exciting influences. The great causative power is 
the puerperal condition. 

Inflammation of the Ovaries or Uterus. It is rare to meet with 
the affection in a non-puerperal patient, as the result of expos- 
ure, unless she be suffering from disease of these organs. Aran 
believes disease in the ovaries to be "almost always the cause." 
It is certain that these organs are generally diseased where the 
affection exists, but it is difficult to determine whether as a com- 
plication, or as the first link in the chain. In the histories of 
fourteen autopsies which I have collected, the state of the ovaries 
is mentioned in ten. Out of these they were affected by inilam- 



358 PERI-UTERI^E CELLULITIS. 

niation in seven. In some of the seven cases, abscesses existed ; 
in others their tissue was destroyed, and in others they had en- 
tirely disappeared. Any chronic or acute disease of either the 
uterine parenchyma or mucous lining, may also result in it, and I 
have more than once seen it follow applications of mild character 
to the cavity of the uterus. 

Direct injury is by no means a rare cause in the non-puerperal 
cases, though it generally proves active in those suffering from 
previous uterine or ovarian disorders. Thus it may follow ope- 
rations upon the neck or body of the uterus, slitting the neck for 
flexion or contraction, for example, or simple dilatation by a 
tent. It may result from efforts at removal of intra-uterine 
growths, and one fatal case with which I have met followed the 
ligation of haemorrhoids. 

Symptoms. — The acute form, and more especially that occurring 
after parturition, is usually ushered in by very decided symptoms, 
of which the most reliable are the following : — 

Chill ; 

Increased local heat ; 

Pain ; 

Fever ; 

Dysuria ; 

Painful defecation ; 

Metrorrhagia. 

The chill, though sometimes absent, is a very general symptom. 

No sooner does it pass off than the pulse rises to 110 or 120, the 

hypogastric region shows increased heat, and pain, which, for a 

number of hours or perhaps days before was just perceptible, 

comes on with considerable violence. With these symptoms 

there will be others pointing to the rectum and bladder, and 

should the affection exist in a menstruating woman the flow may 

be much increased. Even when the patient is not menstruating 

uterine hemorrhage sometimes, though not frequently, comes on. 

But he who awaits these symptoms for diagnosis will be led 

into many errors of omission, for subacute cases very generally, 

and acute cases sometimes, fully develop themselves without them. 

All cases may be brought under three heads as to severity of 

symptoms: — 



PHYSICAL SIGNS. 359 

1st. Cases accompanied by chill, fever, pain, and ordinary signs 
of inflammation ; 

2d. Those accompanied by pain without chill or fever ; 

3d. Those marked by scarcely any symptoms except extreme 
feebleness and some sense of pulsation and weight about the 
pelvis, with hectic fever towards evening. 

Cases which have assumed the chronic form will present them- 
selves with such a history as this ; a patient who was delivered 
one, two, or three months ago has not recovered her strength, but 
is very feeble, has no appetite, and feels nervous, depressed, and 
feverish towards evening. She has no absolute pain, but fears 
that something is wrong about the womb, for now and then she 
feels a sensation of throbbing, tension, and weight about that 
organ, which is increased by defecation, urination, and walking. 
This incites to physical exploration, which establishes the diag- 
nosis. 

Physical Signs. — Physical exploration is the means on which 
we must rely for a rapid and certain determination of the character 
of these cases. Should the finger be introduced into the vagina 
during the first stage, the parts will be found to be very warm 
and perhaps a sense of puifiness may be detected. Upon pressing 
in different directions great sensitiveness will be observed and 
by conjoined manipulation a particularly sensitive point will be 
detected on one side of the uterus. 

As the second stage, or stage of effusion, advances, induration 
occurs in the affected areolar tissue, and then by careful vaginal 
touch combined with external manipulation a tumor as large as a 
nut, a goose's egg, or an orange may be detected in one of the 
broad ligaments, upon one side of the cervix, or on one wall of 
the vagina. 

But the examiner must not suppose that the mere introduction 
of the finger into the vagina will accomplish a discovery which 
often requires the greatest care and most thoughtful attention in 
examination. The finger being passed up to the cervix and the 
other hand placed upon the hypogastrium so as to make counter- 
pressure, it should be carefully pressed into Douglas's cul-de-sac 
and all around the cervix over the base of the bladder and as far 
as possible towards the fundus. Then it should be made in a 
similarly careful manner to traverse the sides of the pelvis where 



360 PEKI-UTEKINE CELLULITIS. 

the broad ligaments are placed, and last of all, those parts below 
the pelvic roof. For one sufficiently practised in this kind of 
examination this procedure will generally be sufficient to deter- 
mine the existence of even a very small point of induration on 
the sides or in front of the uterus. Sometimes, where it is pos- 
terior to that organ, a rectal exploration throws much additional 
light upon the case. 

Should the disease have advanced to its third stage, in addition 
to the signs already noted, the uterus, which, as already mentioned, 
is generally displaced, is now pushed far from its normal position, 
in a direction opposite to the accumulated pus. Sometimes it lies 
upon the floor of the pelvis, at others it is in a state of ante- 
version, retroversion, or latero-version, and, more rarely, sharply 
flexed, the body having remained movable after the cervix was 
fixed. 

In whatever malposition it has been forced it remains to a cer- 
tain extent immovable, from fixation by adhesive lymph. 

Differentiation. — The diseases with which it may be confounded 
are — 

Fibrous tumors ; 
Hematocele ; 
Pelvic peritonitis. 

Fibrous tumors are painless, free from tenderness, and movable 
in the pelvis. They are unaccompanied by chill, fever, and other 
signs of inflammation, and are closely attached to the uterus, so 
as to form part of it. The tumors resulting from cellulitis are 
the contrary of all this, and appear firmly attached, like bony 
growths, to the walls of the pelvis. 

Hematocele occurs suddenly with uterine hemorrhage, and is 
not marked by signs of inflammation, but by prostration, coldness, 
and other symptoms of loss of blood. The tumor created is soft 
in the beginning and grows hard ; that of cellulitis is hard in the 
beginning and tends to softening. 

Pelvic peritonitis shows the ordinary signs of peritoneal inflam- 
mation, great tendency to relapse at menstrual periods, excessive 
pain and tenderness, and produces no distinct tumor in the begin- 
ning, but hardening of the whole pelvic roof. Later, a small 
tumor may be discovered, but it is very high up and attached to 
the uterus and not to the pelvic walls. The uterus is less mova- 



TKEATMENT. 361 

ble than in cellulitis, and when the body is fixed the cervix some- 
times moves nnder pressure. 

Consequences of Cellulitis. — The remote results of this affection 
are so grave, that even if there were no dangers immediately 
connected with it, they would stamp its occurrence as being a 
great disaster. The ovaries are sometimes destroyed by suppura- 
tive action, at others they undergo an atrophy, the result of in- 
flammation, and the Fallopian tubes are often left impervious. 
The uterus is frequently permanently displaced in consequence 
of strong adhesions which bind it in a bad position. From this 
results the fact, that although the disease be cured, the patient is 
often left incapacitated for some .of the most important physio- 
logical functions. Sterility, amenorrhcea, dysmenorrhcea, monor- 
rhagia, tubal dropsy, 1 and displacements may all remain to attest 
the gravity of the original disease, and continue for an unlimited 
time a source of suffering for the patient and discouragement for 
the physician. 

Treatment. — Should the practitioner be called in the acute stage, 
before effusion has occurred, or after its occurrence and before its 
complete organization, leeches should be at once applied over the 
hypogastrium, to the perineum, or around the anus, in sufficient 
number to draw from six to twelve ounces of blood, according to 
the strength of the patient. No false delicacy should induce us 
to apply them from choice to the hypogastrium, for no one will 
question the fact that, when drawing blood from the hemorrhoidal 
veins, they act much more directly upon the pelvic circulation 
than when so placed as to allow the intervention of two layers of 
peritoneum. At the same time that it must be admitted that in a 
nervous, hysterical, or over fastidious patient, the hypogastrium 
might prove the best point for the application, the importance of 
checking so serious an affection before it fully enters upon its 
course is too great to allow any trifling consideration to interfere 
with success. The application around the anus involves no ex- 
posure ; the leeches being placed in a wine-glass, which is held 
against the part until they bite. 

After leeching, warm poultices of powdered flaxseed should 
be applied every third or fourth hour over the hypogastrium, 

1 Aran, op. cit., p. GS3. 



362 PERI-UTEKINE CELLULITIS. 

the bowels kept constipated by opiates, and febrile action, should 
it exist, be quieted by refrigerants and direct sedatives, as tinc- 
ture of veratrum viride or tincture of aconite. 

Another indication which will force itself upon the notice will 
be the relief of pain. This must be accomplished by opiates, 
either by the mouth or rectum, or, if excessive pain exists, ten 
drops of Magendie's solution of morphia may be injected by the 
hypodermic syringe into the cellular tissue of the thigh. 

Absolute rest should be enjoined, the patient not being allowed 
to sit up in bed for a moment, upon any pretext whatever. Were 
I limited to one remedial resource, in this affection, I should 
choose this in preference to all others, but for it to accomplish 
anything it must be absolutely enforced. 

The diet of the patient should be mild and unstimulating, con- 
sisting of milk with farinaceous substances, and tea or coffee. 

So soon as the acute symptoms have passed, and vaginal touch 
informs us that the effused material is becoming thoroughly or- 
ganized, a further effort should be made to break up the morbid 
train before it passes on to suppuration or into chronic indura- 
tion, by the application of a blister six by eight inches over the 
hypogastrium. This should not be applied before febrile action 
and the most acute symptoms have disappeared. 

Some excellent authorities, among others Sir James Simpson, 
object to blistering for fear of strangury resulting. I have never 
had to do otherwise than congratulate myself on its employment. 
Should the case tend to an acute course, and suppuration be im- 
pending, it should be encouraged by constant poulticing. 

As soon as the acuteness of the attack has passed, until which 
time attention should be turned to quieting the general symp- 
toms of inflammation, it is advised by the best authorities that 
the iodide or bromide of potassium should be administered, the 
former in five grain closes repeated every third or fourth hour, 
or the latter in ten, fifteen, or even twenty grains at the same 
intervals. At the same time that I am not prepared to deny 
the utility of these drugs, I confess that I have never been 
able to persuade myself that they really accomplish any good 
result. There is no more certain method of disgorging the veins 
of the pelvis and lower bowel than by acting upon the liver, 
which governs the outlet of the portal system, with which they 



GENERAL MEDICATION. 363 

are connected, and this can most readily be done by mercurial 
cathartics. Thus occasionally used, the mercurials prove of 
great benefit in relieving congestion, which is a leading element 
of the disease. But in doing this we are not developing the spe- 
cific action of this medicine, which here acts as a subordinate, and 
not the chief element of treatment. Its use for the production 
of ptyalism should be avoided, since it is by no means certain 
that it is of decided benefit, and by impoverishing the blood at the 
commencement of what may become an exhausting disease it may 
do absolute injury. As the acuteness of the affection subsides the 
bowels should be kept free by laxative medicines, and the occa- 
sional use of a mercurial in this capacity is indicated. It may 
be necessary to repeat the application of leeches, and the repeti- 
tion of the blister is often called for before the case ends in sup- 
puration or passes into the chronic stage. 

While the patient remains in bed, warm poultices, or towels 
wrung out of warm water and covered by oil silk, should be worn 
over the hypogastrium. An additional emollient remedy of great 
value remains to be mentioned. It is the persevering use of the 
warm douche during fifteen or twenty minutes, night and morning, 
as advised on page 229. The fluid used should be as warm as the 
patient can bear it, and may be slightly medicated by the addi- 
tion of chloride of sodium, tincture of iodine, or iodide of potas- 
sium. These injections act as solvents of effused lymph and, at 
the same time, quiet inflammatory action, in the performance of 
which functions they are invaluable in these cases. 

As the third stage of the disease, or the stage of suppuration, 
merges into pelvic abscess, it will be best to postpone the con- 
sideration of its management to the chapter in which that subject 
is treated. I will merely state here that after an abscess has 
formed and evacuated itself, great care should be taken not to 
allow the patient to exert herself for several weeks, for fear of a 
relapse, and even after she has left the house and begun to exer- 
cise regularly, during two or three menstrual periods she should 
confine herself to bed. 



CHAPTEE XXVI. 



PELVIC PERITONITIS. 



Definition. — Inflammation involving the peritoneum covering 
the female pelvic viscera, and limited to it, receives the name of 
pelvic peritonitis. It must not be supposed that by this definition 
is meant simply that form of peritoneal inflammation arising in 
the pelvis and spreading into general peritonitis, and which has 
long been described as metro-peritonitis. The disease which we 
are now considering is one which is usually strictly limited to 
the pelvis, which presents symptoms peculiar to itself, and rarely 
passes into the general form of the same disorder. 

History. — Long before pelvic cellulitis was known, peritonitis, 
limited to the serous covering of the pelvic organs, had attracted 
attention, and its clinical resemblance to cellulitis, as subsequently 
described, fully noted. Thus Morgagni 1 relates a case in which 
thirty days after delivery, the right ovary and tube were adhe- 
rent to the colon and almost destroyed by an abscess. Nauche, 
in his work on Diseases of the Uterus, published at Paris in 1816, 
described inflammation of the uterus as affecting, first, the mucous 
membrane, second, the parenchyma, and third, the serous cover- 
ing. In 1828, Mad. Boivin credited the adhesions resulting from 
it and binding the uterus down, with a large number of abortions 
attributed to other causes, and, in 1833, she described immobility 
of the uterus, for which she gave as causes, peritonitis, metro-peri- 
tonitis, and pelvic abscess. In 1839, Grisolle 2 distinctly stated 
that "there are cases of circumscribed peritonitis which, producing 
a tumor appreciable to sight and to touch, may lead to the belief in 
the existence of a phlegmon," i. e., a tumor the result of inflam- 

1 Artie. 22, Kpist. 46. Nonat, op. cit., p. 234. 

2 Berautz aud Goupil, op. cit., p. 398. 



HISTORY. 365 

mation of areolar tissue. Lisfranc, 1 writing ten years after Boivin 
and Duges, copies their description very closely in his article on 
" Fixite de la Matrice," without referring to them, and like them 
attributes it to peritonitis or metro-peritonitis. 

Although these facts were known and universally admitted, 
they attracted little notice, and after the description of pelvic cel- 
lulitis by Doherty and Marchal de Calvi, pelvic peritonitis was 
almost entirely lost sight of. This was due to the fact that the 
enthusiasm created by the description of a long forgotten affec- 
tion, caused observers to look upon the results of peritonitis as 
those of cellulitis, and to describe them as such. Thus the matter 
rested until 1857, when M. Bernutz, in a treatise written in con- 
cert with M. Groupil, not only drew especial notice to it, but took 
the position that inflammation of the cellular tissue immediately 
around the uterus, described by Nonat as "phlegmon peri- 
uterin," or what would strictly be termed, in our nomenclature, 
" peri-uterine cellulitis," did not exist as a pathological reality, 
but that the lesions ascribed to it were absolutely due to pelvic 
peritonitis. 

These views, published at first in the "Archiv. Gren. de Med.," 2 
are fully elaborated in the admirable work 3 of these observers 
recently brought forth. They do not touch the general subject of 
peri-uterine cellulitis, as it exists in the broad ligaments, sub-peri- 
toneal tissue, and around the rectum, but only that variety sup- 
posed to have its seat in the areolar tissue between the uterus and 
peritoneum. 

It has been already stated that M. Bernutz was incited to his 
investigations by certain views advanced by M. Nonat as to the 
pathology of peri-uterine induration, which sometimes goes on to 
suppuration. But his researches served not merely to settle this 
comparatively unimportant point, they proved the fact, for which 
the investigator appears to have been himself entirely unprepared 
in the beginning, that many of those cases regarded as instances 
of non-puerperal cellulitis are in reality not phlegmonous but 
peritoneal inflammations. Since the publication of these views I 
have directed my attention particularly to this point, and from 

i Clin. Med., vol. iii. p. 514. « Archiv. Gen., 1857. 

3 Clin. Med. des Femines, 1862. 



366 PELVIC PERITONITIS. 

careful observation, both clinical and post-mortem, feel war- 
ranted in recording the conclusions at which I have arrived in 
the following propositions : — 

1st. Peri-uterine cellulitis is very rare in the non-pregnant 
woman, while pelvic peritonitis is very common ; 

2d. A very large proportion of the cases now regarded as 
instances of cellulitis are really those of pelvic peritonitis ; 

3d. The two affections are entirely distinct from each other, and 
should not be confounded simply because they often complicate 
each other. They may be compared to serous and parenchyma- 
tous inflammation of the lungs, pleurisy, and pneumonia. Like 
them they are separate and distinct, like them affect different kinds 
of structure, and like them often complicate each other. 

4th. They may usually be readily differentiated from each other, 
and a neglect of such thorough diagnosis is as culpable as a similar 
want of care in determining between pericarditis and endocarditis. 

M. Bernutz cites the results of five autopsies 1 by himself, and 
between twenty and thirty by others which presented all the signs 
of pelvic peritonitis and none of cellulitis, although during life 
the symptoms and signs generally attributed to the latter disease 
were present. As an example, conveying some idea of the close 
clinical resemblance between his cases found in autopsy to be 
peritonitis and those ordinarily regarded as cellulitis, I quote the 
salient points in his sixth observation. 

Patient 33, lymphatic temperament, entered hospital ISFov. 24th, 
for feebleness, pain in . the back, emaciation, and dysmenorrhoea. 
After a while loss of appetite, increase of pain, and chills appeared. 
By touch the uterus was found completely fixed, low down in the 
pelvis and inclined to the right side, and attached to it a very sen- 
sitive tumor the size of a hen's egg, extending behind the womb. 
On the 15th of December this tumor was as large as a turkey's 
egg. February 1st : tumor only the size of a pigeon's egg ; a cir- 
cumscribed tumor on the left, attached to uterus and to the walls 
of the pelvis. March 23d: uterus movable and tumor reduced to 
the size of a little nut. April 4th : she died, and autopsy showed 
tubercular pelvic peritonitis, evidenced by tubercular deposit, 

1 I have rejected a number of the cases reported, because not sufficiently con- 
clusive. 



HISTOEY. 367 

lymph, pus, firm, old adhesions, ovaries imbedded in false mem- 
brane and nearly destroyed. 

I had often been struck by the great similarity between peri- 
tonitis and many of the cases of what, until enlightened by M. 
Bernutz, I had regarded as cellulitis, and by the fact that they 
often ran into general peritonitis without any apparent emptying 
of purulent collections into the peritoneal sac, but I never had an 
opportunity of examining such cases post-mortem until the fol- 
lowing, of which I give only a short sketch here, as it is else- 
where 1 fully related. 

Mrs. M., aged 35, married, but never pregnant, was under my 
care, during the winter, at the Woman's Hospital, for anteflexion 
of the uterus, the result, as I supposed, of peri-uterine cellulitis. 
August 6th : I was called to see her in consultation with Dr. Eoth, 
her family physician, and found her suffering from severe pelvic 
pain, constant vomiting, and fever. Upon vaginal touch I found 
the uterus immovably fixed and the pelvic roof as hard as a board. 
The pelvic tissue was everywhere hard and resisting, and the 
physical signs of what I had habitually styled cellulitis were 
presented. About a week afterwards the patient died suddenly 
and unexpectedly, and I held an autopsy in presence of Drs. Eoth 
and J. B. Smith. No general peritonitis existed ; the left ovary 
presented a sac the size of a hen's egg, filled with pus ; the pelvic 
peritoneum was intensely inflamed and the uterus bound down by 
old false membranes, bands of which matted all the parts together. 
The vermiform appendage was bound to the right ovary and the 
caput coli lay just below the uterus. No trace of inflammation 
could be discovered in the pelvic cellular tissue except, of coarse, 
that in immediate contact with the ovary. 

The fixation of the uterus, observed during life, was due to 
lymph effused upon the pelvic peritoneum, and no trace of inflam- 
matory action in the pelvic areolar tissue could be discovered as 
accounting for it. It is true that the left ovary, enveloped by the 
layers of the broad ligament, was inflamed, and that a certain 
amount of inflammation existed in the cellular tissue immediately 
surrounding it, but this did not extend. There could be no 
question of the facts which are here stated. 

Frequency. — A reference to the autopsic notes of cases of cellu- 

1 Chap, ou Ovaritis. 



363 



PELVIC PERITONITIS. 



litis, for example, those recorded by vVest, Nonat, Aran, and 
McClintock, will give abundant evidence of the almost universal 
attendance of this complication upon it. But, even without the 
existence of that disease, Aran found it in greater or less degree 
in fifty five per cent, of cadavers of women examined in his ser- 
vice. This proves that peritonitis, limited to the pelvic viscera, 
is a common affection, and one which is very generally overlooked. 
It is probably to its occurrence that are due so many of those at- 
tacks of violent hypogastric pain occurring with menstruation, 
or just after it, accompanied by vomiting and slight febrile action, 
and which are generally treated by domestic remedies and viewed 
as cramp or uterine colic. 

Pathology. — The disease runs its course here, as peritoneal in- 
flammation does elsewhere, in three stages. "With the first there 
are simple engorgement and turgescence of the vessels, producing 
redness, dryness, and pain. In the second stage an entirely differ- 
ent state of things will be found to exist, to comprehend which 
fully, the reader must bear in mind what is meant by the " roof 
of the pelvis." If a plane be passed backwards from a point just 
under the pubic arch, through the cervix uteri at the attachment 
of the vagina, to the sacrum at the attachment of the utero-sacral 



Fig. 152. 




The straight line represents approximative!}- the roof of the pelvis ; 
the dotted line represents it more exactly. 

ligaments, it will correctly represent this roof, which is thus 
formed by the vesico-vaginal septum, the lower extremity of the 



causes. 369 

uterus, which projects, as it were, through a hole in the roof, the 
upper part of the fornix vaginae, and the utero- sacral ligaments. 
Above the plane, the organs of reproduction float, -as Nonat ex- 
presses it, " in an atmosphere of cellular tissue." Let the reader 
suppose that instead of this yielding, springy tissue, these organs 
were fixed in their places by having a fluid mixture of plaster of 
Paris poured around, among, and over them, which had after- 
wards become solid, aod he may form a correct idea of what 
vaginal exploration will yield to the sense of touch in the second 
stage. The roof of the pelvis is hard, ligneous, and as if com- 
posed of a " deal board," to which Prof. Doherty likens it. The 
uterus, which is generally much displaced, is immovable, and all 
its appendages appear fixed by some solid, surrounding element. 
This, the second, stage consists in a collection of plastic lymph 
on the surface of the peritoneum, and of serous, purulent, or sero- 
purulent fluid in its most dependent parts. 

In the third stage the fluid, if serous, is absorbed, if purulent, 
discharged, and the exuded lymph undergoes organization and 
subsequently contraction. This binds the uterus, its appendages 
and some of the intestines together in a mass, which yields all 
the physical signs of a tumor. 

Causes. — Its causes are as follows: — 

Peri-uterine cellulitis ; 

Parturition or abortion ; 

Gonorrhoea ; 

Metritis, ovaritis, or salpingitis ; 

Escape of fluids into the peritoneum ; 

Traumatic influences ; 

Imprudence during menstruation ; 

Tubercular or cancerous deposit. 
Its frequent dependence on the first needs no further mention. 
As a result of parturition or abortion, it is so well known as to 
make the exhibition of proof here almost unnecessary. Eeference 
may be made, however, to 53 autopsies by Aran, 1 in which out of 
38 women who had borne children, 24 presented evidences of its 
previous existence, while out of 15 who were nulliparous, only 
5 did so. • 

1 Op. cit., 71S. 
24 



370 PELVIC PERITONITIS. 

Gonorrhoea, by passing into the uterus and through the Fallo- 
pian tubes, is a fruitful source of the affection. According to M. 
Bernutz 28 out of 99 of his cases had this origin. I have at pre- 
sent a very distinct case under treatment, which was produced in 
a lady two weeks after marriage, the disease having been con- 
tracted by her husband four days before, and showing itself in 
him on the very day of the ceremony. 

It would be strange if ovaritis and metritis did not, at times, 
cause pelvic peritonitis. That they frequently do so, is abund- 
antly demonstrated by autopsies made after their existence both 
in the puerperal and non-puerperal states. 

Salpingitis causes it not only by the extension of inflammation 
along the mucous, into the serous membrane which is continuous 
with it, but by emptying its accumulations into the peritoneal 
cavity. 

Escape of fluid into the peritoneum is an undisputed cause of 
this, as of general peritonitis. I have myself produced a well 
marked case which almost terminated fatally, by injecting a solu- 
tion of persulphate of iron into the uterine cavity. The passage of 
the fluid through the tubes could not be questioned, for agonizing 
pain came on in less than three minutes, and continued up to the 
development of inflammation. This danger has caused the almost 
entire abandonment of intra-uterine injections on the part of the 
majority of practitioners in New York, and I think elsewhere, 
unless the cervix be previously dilated by tents. But many other 
sources from which fluid may enter the peritoneum exist ; as, for 
example, rupture of an ovarian cyst, discharge of tubal dropsy, or 
of a pelvic abscess, intra-peritoneal hemorrhage, regurgitation of 
obstructed menstrual blood, &c. 

Traumatic influences, as blows, falls, injury during labor, punc- 
tures, &c, may result in partial, as they do in general, inflamma- 
tion of the peritoneum. 

Imprudence during Menstruation. — During a period in which a 
physiological function involves rupture of the peritoneum and 
produces hemorrhage, which must pass to the uterus by a narrow 
tube not permanently in immediate contact with the ovary, any 
degree of exposure must evidently tend to inflammation in the 
ruptured part. Of M. Bernutz's 99 cases, 20 were thus produced. 

Tubercles deposited in the part, either on the peritoneum, or in 



VARIETIES — SYMPTOMS. 3/1 

the tissue of the tubes or uterus, may, as they do elsewhere, result 
in secondary inflammation, and cancerous or cancroid degenera- 
tion would be still more likely to produce the same result. 

Varieties. — The disease may assume either the acute or chronic 
form, though when occurring as the main morbid element it gene- 
rally in the beginning presents the features of the first. When 
it occurs as a complication of cellulitis, tuberculosis, or uterine 
disease, it assumes from the beginning the chronic type. Yery 
often those cases which are destined to assume the chronic form 
present themselves thus ; the patient states, that on one or several 
occasions, after miscarriage or during menstruation, perhaps, she 
has had severe cramping pain in the lower bowel, which she sup- 
posed to be due to some intestinal disorder, but the effects of 
which had never entirely passed off. This she believes to be the 
case from the fact that ever since the primary attack she has suf- 
fered from pain in locomotion, dysmenorrhea, leucorrhcea, and 
perhaps menorrhagia. In spite of these symptoms, she attends to 
her usual avocations and fulfils all her functions as a wife. The 
historj^ pointing to disease of the pelvic viscera, an examination 
is instituted which discovers the existence of the affection we are 
considering. 

Symptoms. — The acute form shows itself by — 
Pain and tenderness ; 
Fever ; 

Nausea and vomiting ; 
Anxious facies ; 
Mental disturbance. 

When a severe acute attack sets in it may cause either a chill, 
or a sensation of coldness so slight that the patient will not recall 
its occurrence unless her attention be especially directed to it ; 
or pain and fever may show themselves without this symptom. 

Pain is at times only moderate, but at others most severe. It 
may occur in paroxysms, which create the greatest agony and 
prostrate the patient by their severity. I have seen it amount 
to agony equal to that arising from the passage of a biliary cal- 
culus, causing the patient to roll in bed, seize the bed-clothes 
in the teeth, and cry aloud most piteously. As a rule it is not so 
violent as this. Pain may show itself quite early in the disease. 



372 PELVIC PERITONITIS. 

or may be preceded for several days by pelvic -uneasiness and 
weight. 

Tenderness over the whole hypogastrium accompanies it to such 
a degree, that even the weight of the bed-clothes is intolerable, 
and the patient, to relieve it, lies upon the back with the legs flexed 
in order to relax the abdominal muscles. 

The pulse shows in slight cases very little, and in severe cases a 
considerable amount of febrile action. It is small and wiry, and 
increases to 110 or 120 to the minute. 

Nausea and vomiting are common symptoms, though they do 
not generally exist to such a degree as to prove very annoying. 

The facies is peculiarly anxious, and is sometimes rendered very 
striking by the appearance of dark circles around the eyes. 

I have generally noticed in acute cases that the mind is 
markedly disturbed, as if the patient instinctively dreaded some 
serious disease. 

It may justly be observed that these are the symptoms which 
mark general peritonitis. This is true ; it is merely the slighter 
degree of severity and the localization of pain and tenderness, 
which will point to the partial nature of the affection. 

With reference to general peritonitis, it may be stated that, on 
the one hand, it, of all diseases, may declare itself by the most 
numerous and characteristic symptoms, or, on the other, run its 
fearful course with the greatest obscurity, so as to mislead the 
most careful diagnostician, even up to its latest stages. If this be 
true as to the general disorder, how much more must it be so as 
to the local. Thus it is that we find the subacute and chronic 
forms passing off without recognition, and the fact that they have 
existed being known only by the discovery of firm adhesions over 
the whole pelvic roof in post-mortem examinations. In these 
varieties, there are less pain and tenderness and less tendency to 
nausea and febrile action than in the acute. Sometimes, indeed, 
there is merely a sense of local discomfort, increasing to pain at 
menstrual periods, accompanied by fever towards evening, by 
difficulty in locomotion, and by a general sense of feebleness and 
malaise. 

Physical Signs. — Should an examination be made during the 
first stage, nothing will be ascertained but the existence of sensi- 
tiveness upon pressure in the vaginal cul-de-sac and upon lifting 



PHYSICAL SIGNS. 373 

the uterus. Tenderness will likewise be demonstrated by pressure 
on the hypogastrium. None of that doughy, oedematous, puffy 
feel which accompanies cellulitis will be discovered by vaginal 
touch. Should the disease run its course as one of those very 
insignificant attacks, which produce no grave symptoms and are 
scarcely recognizable, no other physical signs will present them- 
selves at this or any other period. Should it be one of graver 
character, a sense of resistance merely, or a tumefaction like an 
ill-defined tumor, may be felt in the recto-vaginal space or at the 
side of the uterus. Or if very little lymph and much sero-pus 
has been the result of the inflammatory action, a sense of fluctua- 
tion may be detected very early. The uterus is always more or 
less interfered with in its mobility, and in severe cases it is abso- 
lutely immovable. This explains how Lisfranc and Boivin ap- 
plied to it the name of "fixity" or " immobility" of the uterus. 

I have stated that a tumor is commonly felt posterior to, or at one 
side of, the uterus. This tumor, which is formed by agglutination 
of the pelvic and abdominal viscera, is extremely sensitive to 
touch. 

If the disease goes on to formation of pus, the sense of tume- 
faction may disappear as this discharges itself, but if the effused 
lymph becomes thoroughly organized, it remains hard and resist- 
ing for a length of time. This accumulation almost invariably 
displaces the uterus, sometimes by pressing it in an inverse direc- 
tion, sometimes by drawing it towards itself as the lymph contracts. 
In a case which I saw a year ago with Prof. Greorge T. Elliot, we 
were much puzzled, for a short time before its fatal issue, by the 
existence in the fornix vaginas of a pouch, apparently filled with 
fluid, all the surrounding parts being unattached and no sense of 
tumefaction or resistance discoverable. The patient died suddenly 
from general peritonitis, and upon post-mortem examination, con- 
ducted by Prof. J. W. S. Grouley, we found, first, a small piece of 
fetid placenta in utero, the result of a recent abortion ; second, 
abscess of the right ovary, which had created general peritonitis 
by emptying itself into the peritoneum ; and third, pelvic perito- 
nitis, which had evidently existed for more than a week. It had 
created a purulent collection in Douglas's cul-de-sac, which was 
limited to this space by false membranes, that formed for it a 



374 PELVIC PERITONITIS. 

complete roof. This accumulation, it was, which gave the sensa- 
tion above described. 

In another case, sent to me by Prof. J. C. Hutchison, of Brook- 
lyn, the uterus was found firmly bound to the sacrum by a hard, 
resisting mass, which was very sensitive. As there was considera- 
ble corporeal endometritis, I incautiously applied to the uterine 
cavity tincture of iodine, and as a result the most violent pelvic 
peritonitis developed itself, which almost became general. In ten 
days after its inception, a soft, fluctuating pouch formed in the 
fornix vagina?, which became so painful that I tapped it with an 
exploring needle and drew off about an ounce of clear serum, 
much to the patient's relief. 

Course, Duration, and Termination. — In no disease can these be 
more variable and uncertain than in that under consideration. A 
great similarity exists between its phases and those of pleuritis. 
As in it we have shades of difference, varying from the ordinary 
" stitch in the side," which results from inflammation of a portion 
of the pleura not larger perhaps than a silver half dollar, to em- 
pyema and tubercular pleuritis, which may continue till death by 
pulmonary consumption or pneumothorax closes the scene, so we 
may have them in pelvic peritonitis. It may run its course un- 
observed, leaving evidence of its existence only in adhesions found 
post-mortem. It may pass through its first two stages in three 
or four weeks, leaving the uterus permanently displaced by the 
continuance of the third. It may reappear with a certain amount 
of acuteness at each menstrual period, causing them to be very 
painful. It may, if due to tubercular deposit, continue so as 
slowly to exhaust the patient. It may produce a purulent collec- 
tion, which, by emptying itself into the peritoneum above the 
adhesions thrown around it, creates general peritonitis, or this 
last may result from the spread of morbid action from the pelvic 
to the general serous membrane. 

Differentiation. — The diseases with which this is most likely to 
be confounded are — 

Peri-uterine cellulitis ; 
Pelvic hsematocele ; 
Fibrous tumors. 

Peri-uterine Cellulitis. Differentiation between these two affec- 
tions is in severe cases simple enough, but in milder forms it is not 



DIFFEKENTIATION. 



375 



so. Difficulty will occur when cellulitis affects, and is confined to 
the tissue most immediate to the uterus, bat this we know to be 
very rare. Our suspicions will often be turned into the proper 
channel by the cause of the attack. Cellulitis will very rarely 
occur except after parturition, abortion, or an operation on the pel- 
vic viscera. Peritonitis will usually result from exposure during 
menstruation, disease of the ovaries, or collection of fluid in the 
peritoneum. Should the attack occur as a result of gonorrhoea, 
it is probably due to serous and not cellular inflammation, a fact 
which the anatomical relations would lead us a priori to anticipate, 
and which is fully substantiated by statistics. West and Aran 
credit gonorrhoea with the causation of cellulitis in from one to 
two cases in a hundred, and Bernutz declares it active in twenty- 
eight out of a hundred of peritonitis. 

Other signs by which we may arrive at a decision may thus 
be tabulated : — 



PKRI-UTERINE CELLULITIS. 

1. Tumor easily reached, generally 
felt in .broad ligaments, and may be felt 
above pelvic brim ; 

2. Marked tendency to suppuration ; 
8. Abdominal tenderness chiefly over 

iliac fossae ; 

4. Tumefaction generally noticed late- 
rally in the pelvis ; 

5. No constitutional signs of peritoni- 
tis present ; 

6. Tendency to monthly relapses not 
marked ; 

7. Retraction of thigh not rare ; 

8. Pain severe and steady ; 

9. Facies not much altered ; 

10. Nausea and vomiting not exces- j 
sive ; 

11. Does not necessarily displace ute- | 
rus ; 

12. Not accompanied by tympanites ; ; 

13. Uterus fixed to limited extent. 



PELVIC PERITONITIS. 

1. Tumor very high, only in vaginal 
cul-de-sac, does not extend above supe- 
rior strait ; 

2. Suppuration rare ; 

3. Abdominal tenderness excessive 
above brim of pelvis ; 

4. Generally noticed near or upon the 
median line ; 

5. Constitutional signs of peritonitis 
present ; 

6. Tendency to relapse every month 
very marked ; 

7. Retraction of thigh never occurs ; 

8. Pain excessive and often paroxys- 
mal ; 

9. Facies very anxious ; 

10. Nausea and vomiting often exces- 
sive ; 

11. Always displaces uterus ; 

12. Always accompanied by tympa- 
nites ; 

13. Uterus immovable on all sides. 



Pelvic Hematocele. From this it may be distinguished by the 
great suddenness of appearance of hematocele, absence of signs of 
inflammation, presence of those of hemorrhage, and by the much 



376 PELVIC PERITONITIS. 

greater dimensions of the tumor, which unlike that of peritonitis 
is at first rather soft and gradually becomes hard. The occur- 
rence of bloody flow will likewise point to hematocele. Two 
facts in this connection must not be lost sight of: one, the rarity 
of hematocele and frequency of pelvic peritonitis; the other, that 
the former will sometimes excite the latter and thus that both 
may exist together. 

Fibrous Tumors. These will generally be known by their pro- 
ducing no pain, presenting no sensitiveness on pressure, no sense 
of oedema, signs of inflammation nor rapidity of development. 
They are likewise movable and cause no fixation of the uterus. 

Importance of Differentiating Peritonitis from Cellulitis. — The 
importance of differentiating this disease from cellulitis rests in 
part upon the fact that it admits of less local interference. Some- 
times the passage of a uterine sound, an application to the cavity, 
or even the use of a cold vaginal injection which by accident has 
entered the uterus, have been known to destroy life by creation 
of peritonitis which has extended to the whole cavity. It is like- 
wise important in reference to prognosis as to the course of the 
affection and its remote results. Lastly, it should not be for- 
gotten that progress in the comprehension of the diseases of all 
organs must be preceded by a careful and systematic separation 
of them, one from the other. As the study of acute cardiac affec- 
tions under the common name of carditis could never have accom- 
plished what that of each of its varieties has done, so could not 
investigation of these affections, undivided into their proper 
classes. 

Prognosis. — If the case follows parturition or abortion, the 
prognosis will be rendered graver by that fact. Otherwise it will 
be governed in great degree by the general symptoms. Should 
these show great intensity of inflammation ; and constitutional dis- 
turbance be evidenced by excessive nausea and vomiting, quick 
pulse, anxious facies, &c. ; in other words, should the symptoms 
point to the probable spread of the disease to the whole serous 
sac, the ordinary prognosis of peritonitis may be made. In cases 
of chronic type, occurring in the non-puerperal state, it is de- 
cidedly favorable, unless the disease exist in a scrofulous or 
tuberculous patient, or show a tendency to severe monthly re- 
lapses. Another fact, which will increase the gravity of progno- 



TREATMENT. 377 

sis, is the existence of purulent effusion in place of lymph and 
serum as the result of the inflammatory action. 

Results. — The common results of the disease, which remain 
long after it has passed away, or perhaps permanently, are de- 
struction of the ovaries by abscess or atrophy ; obliteration or 
dropsy of the tubes of Fallopius, and fixation of the womb in 
malposition, by organization of false membranes. As conse- 
quences of these lesions follow, very naturally, amenorrhcea, 
dysmenorrhoea, and sterility. 

Treatment — Should the medical attendant be called in the first 
stage, leeches, if they can be tolerated, should be applied over 
the hypogastrium, and a poultice, as warm as can be borne, should 
follow them immediately. The patient should be brought fully 
under the influence of opium by mouth, rectum, or the hypo- 
dermic syringe, and perfect rest should be enjoined. No cathartic 
medicine should be given, as it interferes with quietude, and very 
often it is well to keep the bladder empty by the sigmoid catheter. 
Milk, beef-tea, and other plain, nutritious and unstimulating food 
should be prescribed. 

In the second and third stages, where lymph has been the chief 
and perhaps only product of inflammation, we must rely upon 
counter-irritants, and I know of none to be compared with the 
blister. One made of Spanish flies, four by six inches in dimen- 
sions, should be applied over the hypogastrium and its abrasion 
dressed with savine ointment. As soon as it heals entirely another 
should be applied directly over the newly-formed skin, and this 
may be repeated every ten or fourteen days with great advantage. 
I have known patients who dreaded them in the beginning beg 
for them after experiencing the relief which they gave. Should 
the patient be rendered so nervous by this remedy that it can- 
not be employed, or should any other reason prevent its use, nitric 
acid issues may be' applied over the iliac regions and kept open 
by issue peas or occasional cauterization with solid nitrate of 
silver. The blister is to pelvic peritonitis what it is to pleuritis, 
the most rapid and efficient of remedial agencies. 

Another very excellent method for producing counter-irritation 
is by tincture of iodine painted over the hypogastrium once in 
twenty -four hours for weeks. 

Treatment of Chronic Cases. — The affection having passed into 



378 PELVIC PERITONITIS. 

the chronic stage, or originated with all the appearances of chronic 
disease, a different course of management becomes advisable. The 
patient should not be so strictly confined to bed nor dieted. She 
has entered upon an invalid course which may last for months or 
for years, and in making a strenuous effort to cure her local dis- 
order we may sap her general health and do her irretrievable 
injury. On the other hand, she should not attend to her house- 
hold cares, nor take exercise to any great degree; but remaining 
in bed or on a lounge most of the time, go out in the fresh air for 
an hour or two daily. Her diet should be of the most nutritious 
character, stimulants should be allowed in moderation, and the im- 
poverished blood resulting from a combination of circumstances 
prejudicial to hsematosis, combated by change of air and the use 
of vegetable and mineral tonics, especially of iron. 

One of the most important questions in the management of 
chronic cases is that of the amount of exercise to be allowed, and 
the strictness of confinement to be practised. No absolute rule 
can be laid down in reference to these points, for each case will 
call for special guidance, based upon careful experiment. In 
general terms it may be stated that when motion does not produce 
pain or discomfort, the patient should ride in an easy carriage for 
two or three hours daily. In those cases which are still free from 
local trouble, she may walk with moderation; while in others 
which present elements of acuteness, no motion whatever should 
be allowed. 

Sometimes the patient will even bear removal from home to 
the sea-side or some watering-place during the summer. If this 
be so a locality should be chosen which is accessible by other 
means than railroad travel, which is peculiarly prejudicial. One 
great and ever recurring difficulty in this connection arises from 
the great tendency of patients allowed to take exercise to commit 
indiscretions by overtaxing themselves. This becomes so great 
at times as to make it advisable to confine to bed one who would 
be benefited by moderate exercise in order to avoid danger from 
her imprudence. The fact should never be lost sight of that the 
pelvic peritoneum forms a part, a sheath, as it were, of the sus- 
pensory ligaments of the uterus. The fibrous -structure of the 
round, broad, sacral, and vesical ligaments is covered by it, so that 
dragging of the uterus upon them puts the peritoneum upon the 
stretch and strongly tends to excite renewed action there. 



METHODS OF EVACUATION. 379 

Of all influences which act in a directly prejudicial manner 
upon these cases, sexual intercourse is the most decided, and its 
absolute interdiction should be made one of the first rules laid 
down for their management. 

Should acute exacerbations occur in chronic cases, the use of 
local depletion would be indicated, but as a plan to be strictly 
pursued with reference to cure it is highly objectionable on ac- 
count of the spanasmia which it induces. 

If it be deemed advisable to keep up the use of the iodide or 
bromide of potassium, the results of which are, however, doubtful, 
they may, with advantage, be combined with iron and vegetable 
tonics as in the following prescriptions : — 

R. — Potassii iodidi, gv. 
Ferri iodidi syr., §iv. 
Tr. calumbae, ,^iv. — M. 
A dessertspoonful (gij) in water three times a day. 

R. — Potassii bromidi, 3 v. 

Yini ferri dulcis, !|iv. 

Tr. calumbse, %iv. — M. 

A dessertspoonful in water three times a day. 

Should collections of pus or serum be evacuated? The important 
bearings of this question are manifest, but unfortunately no defi- 
nite answer can be given to it. In evacuating these collections 
the peritoneal cavity is not exposed to entrance of air, for a false 
membranous roof covers the collection, but there is always danger 
in perforating the delicate and easily inflamed serous sac. I have 
elsewhere reported a case in which I drew off one or two ounces 
of serum under these circumstances to the great relief of the 
patient, who rapidly improved and did well. It is the only case 
in which I have ventured to invade the peritoneum under these 
circumstances. The safest rule for practice will be this : if in spite 
of the purulent collection the patient is doing well and does not 
suffer from the local trouble, it should be left to empty itself 
spontaneously. If, on the other hand, the patient suffers from the 
collection and is not progressing favorably, it should be evacuated. 

Methods of Evacuation. — Evacuation may be accomplished by a 
small trocar and canula, or by a guarded bistoury or tenotomy 
knife. After evacuation the sac should not be injected, lor evi- 
dent reasons, although such a course has been advised. 



CHAPTEE XXVII 



PELVIC ABSCESS. 



Definition. — Upon this point little need be said, as any purulent 
collection originating in, and not simply passing through, the 
pelvis, conies under this head, regardless of its cause. 

Pathology. — There are three sources of pelvic abscess: 1st, 
breaking down of tuberculous material deposited in any of the 
tissues of the part; 2d, suppurative action taking place in the 
walls of a cavity formed by an hematocele or ovarian cyst ; 3d, 
inflammatory suppuration in the areolar tissue, the ovaries, or 
tubes, the pelvic peritoneum, or the parenchyma of the uterus 
itself. Of all these sources the third is decidedly the most fre- 
quently met with, and is most generally the result of cellulitis, 
occurring after parturition or in the non-puerperal state. Under 
the latter circumstances it may be primary, or secondary to irri- 
tation from some foreign body, as the debris of an extra-uterine 
foetus, a hard substance in the vermiform appendix, or a fibrous 
tumor of the uterus. 

Causes. — Anything, then, which induces cellulitis, or either of 
the other two pathological conditions mentioned, may prove im- 
mediately causative of abscess. As remote causes may be men- 
tioned the tuberculous, scrofulous, or syphilitic diatheses, great 
depression of the vital energies from any cause, as impure air, 
like that of a hospital, the puerperal state, or pyaemia. 

Symptoms. — These will not differ essentially from those of 
abscess elsewhere. When pus is forming, violent chills, followed 
by fever, with profuse sweating, are likely to occur. Then a 
feeling of prostration with throbbing pain in the pelvis, pres- 
sure upon the rectum and bladder, and sometimes interference 
with urination, present themselves. Pain down the thigh, which 
may be mistaken for sciatica, will also at times be noticed. 



DIFFERENTIATION". 381 

■ 

Physical Signs. — By abdominal palpation, combined with rectal 
or vaginal touch, a fluctuating tumor will be felt, presenting the 
ordinary physical signs of such collections elsewhere. 

Course, Duration, and Termination. — Pelvic abscesses may evacu- 
ate themselves through any part of the floor of the pelvis, through 
its roof into the peritoneum, through any one of its three anterior 
sides by means of foramina, through any of the pelvic viscera, or 
by several of these channels at the same time. They may open 
by free outlet or by a long sinuous tract, which renders prognosis 
as to cure extremely grave. The most favorable means of evacua- 
tion are through the vagina and rectum. Next to these comes, 
in point of favorable prognosis, evacuation through the abdominal 
walls. Nonat declares that when the collection " opens simulta- 
neously into the intestine and bladder, death is almost inevitable." 
In the "Charleston MedicalJournal," for 1853, 1 published a fatal 
case of this character with autopsy. Sometimes, when left to 
themselves, these abscesses will go on to recovery without delay, 
opening into and discharging themselves through some of the 
parts mentioned and gradually contracting and disappearing. If 
deprived of the assistance of art, they may burrow deeply into 
the tissues, open by long fistulous tracts into some organ, as the 
large intestine or sigmoid flexure, or discharge into the perito- 
neum. 

Sometimes, even when the opening is large, it contracts so as 
to allow only an imperfect discharge of the contents of the sac. 

Then hectic fever arises, and the patient either leads a miser- 
able existence for years from the constant fetid flow, or is worn 
out by exhaustion or septicaemia. At other times these collec- 
tions of pus will remain imprisoned for a long period, without 
any attempt at escape. 

Differentiation. — The morbid states with which it may be con- 
founded are these : — 

Pelvic hematocele ; 
Extra-uterine pregnancy ; 
Displaced ovarian cyst ; 
Hydrometra ; 
Tubal dropsy. 

The first of these being a hemorrhage, gives certain symptoms 
inherent to that accident, as prostration, coldness of the surface, 



382 PELVIC ABSCESS. 

I 

great suddenness of appearance, &c, and absence of chill, heat, 
fever, and other signs which are likely to accompany abscess. 

With the second, the signs of pregnancy exist, and as early as 
the fourth month foetal movements may be detected, while the 
perfect health of the patient with absence of menstruation will 
excite suspicion as to the character of the affection. 

Around abscesses, even of tubercular character, there is always 
a wall of lymph thrown up which would not be present in a dis- 
placed ovarian cyst. All the rational signs of suppuration would 
likewise be absent in the latter. 

He who confounds the distended body of the womb with abscess 
would surely be very culpable, for the spherical shape of the 
body and the light obtainable from the uterine probe should be 
guides by which to avoid error. 

Tubal dropsy is generally the result of inflammatory action 
affecting the Fallopian tubes and closing both uterine and ovarian 
extremities, at the same time that it causes a secretion, which 
distends the intermediate canal. The fluctuating tumor thus re- 
sulting being produced by inflammation and being often attached, 
in consequence, to the surrounding parts, would offer difficulties 
in diagnosis which might well prove insurmountable. If an error 
were made, however, no evil would result from it. 

Prognosis. — The prognosis will depend upon the following 
circumstances: it will be favorable if the abscess is superficial, 
points upon a mucous tract, opens low down in the pelvis by free 
exit, and gives forth pus which has no offensive odor. Should 
it be deep seated, open by a long tract, give forth fetid pus, open 
high up and by two points of exit, as, for example, the bladder 
and bowel, or abdominal wall and bowel, the prognosis is deci- 
dedly unfavorable, unless the case can be so altered by surgical 
interference as to change its character. 

Treatment. — Nothing can be done in these cases by specific 
medication, by which I mean that directed especially to relief of 
the existing morbid condition. All of our efforts should be 
directed to supporting the vital forces which are always much 
prostrated by the process of suppuration. The patient should 
take the most nutritious diet, as much animal food as she can 
digest, eggs, milk, fresh vegetables, and malt liquors. Whiskey 
or brandy should be allowed her, and the blood state should be 



TREATMENT. 383 

improved as much as possible by vegetable and mineral tonics. 
Those most especially suited to the condition are preparations 
of cinchona and iron, as, for instance, the following pill : — 

R. — Quiniae sulphat., 9ij. 
Ferri sulphat., 9j. 

Acid, sulph. arom., gtt. x. 
Mucilage acacise, q. s. — M. et ft. pil. No. xx. 
S. — One to be taken three times a day before meals. 

But it is to surgery that we must look most confidently for 
aid, and in this connection arises the important question as to 
the propriety of opening such abscesses, the best point for evacu- 
ation, and the time for interference. 

Is it best to open them f — Should an abscess in the pelvis show a 
rapid tendency to point and discharge through a favorable chan- 
nel at the same time that no distressing or dangerous symptoms 
show themselves, it would be the part of wisdom to await the 
action of nature, for all must admit that there are few localities 
in the body into which it is more hazardous to cut than this. 
Even under these circumstances, however, there is danger in 
delay. Sir James Simpson relates a case which he saw with 
Dr. Ziegler one day when the abscess pointed decidedly towards 
the vagina and rectum very low down. Feeling sure that it must 
soon discharge, they left it till next day, but before that time, to 
their dismay, it had burst into the peritoneum. This danger as 
evidenced by statistics is not great, and as experience goes to prove 
that the knife is often employed too early, rather than too late, 
I should strongly recommend the delay of surgical interference 
as long as possible. If it be delayed, the tissue intervening 
between the pus and the point of introduction of the instrument 
becomes broken down, and thus a tract or sinus is avoided ; if 
two or three abscesses exist near each other, we give time for 
them to coalesce, and the mass of lymph poured out is liquefied 
by the suppurative process. If surgery comes in too soon, all 
these advantages will be lost. 

Let us suppose a different case, that the patient is suffering- 
grave constitutional signs from the abscess, The answer to the 
question of the propriety of interference resolves itself into this : 
if the pus can be certainly, easily and safely reached, it should 
be evacuated. Should the abscess be deeply seated, on the 



384 PELVIC ABSCESS. 

other hand, so as to make the operation the opposite of this, it 
would expose the patient to hazards greater than those attendant 
upon delay. 

The best Point for Evacuation. — To whatever surface the point 
of the abscess is nearest, that will, as a general rule, be the best 
for its evacuation. If there be a choice, the locations at which 
it will most likely point should be chosen in this order : 1st, the 
vagina ; 2d, the rectum ; 3d, the abdominal walls. 

The Proper Time for Evacuation. — If possible, the operation 
should be delayed until all the lymph effused has been softened 
down, until all the abscesses have coalesced, arid until the accu- 
mulated pus has broken down the mass of tissue between itself 
and the channel of evacuation. 

Methods of Operating. — The propriety of opening the abscess 
having been determined upon, the operator, if he intends reaching 
it through the vagina or rectum, should carefully investigate, by 
touch, as to* the presence upon their walls of large bloodvessels, 
the opening of which might prove a source of serious hemorrhage. 
The patient being placed on the left side and Sims's speculum 
introduced, if the abscess be superficial, a trocar and canula may 
be plunged into it. If it be deeply seated, a bistoury may be em- 
ployed, not to plunge in, but to cut line by line through the over- 
lying tissues until it is reached. An anaesthetic should always be 
administered, as perfect quietude is essential to safety. If the 
opening made be large enough to admit the finger, it should be 
passed in and by it any tract leading into an adjoining abscess 
should be enlarged, and any sloughing tissue met, removed. 
After this, should there be any fear of closure of the canal just 
opened, its walls may be touched by nitrate of silver, or painted 
with solution of persulphate of iron, or a sponge tent, or piece 
of gum-elastic catheter may be left in it. 

If it be thought best to select the abdominal surface as the 
point of evacuation, all danger of escape of. pus into the perito- 
neum should be avoided by following the suggestion of Kecamier 
with reference to hepatic cysts, namely, causing adhesion of the 
layers of the serous membrane by a nitric acid issue over the point 
of selection. The trocar may be plunged through the centre of the 
issue without the danger just mentioned. 

Should the operator open any large vessel in the vaginal walls, 



MEANS FOE CAUSING CLOSURE OF THE SAC. 385 

hemorrhage may be checked by applications of persulphate of 
iron, the vaginal tampon, or, should these not prove effectual, the 
actual cautery. 

Means for Causing Closure of the Sac. — Sometimes, after the 
evacuation of these abscesses, their sacs will not close, but, re- 
maining open for months and even years, go on pouring out large 
quantities of pus. 

The causes of their not closing are these — the existence of 
sinuses, which will not allow their complete evacuation ; a pecu- 
liar condition of their walls from the existence of a membrane, 
called by Delpech pyogenic, which tends to prolong suppuration ; 
or the passage into the sac of air or feces from the intestines, or 
urine from the bladder. 

Of these the first is decidedly the most frequent, and should be 
met by dilatation of the tract leading to the abscess, by tents of 
sponge or laminaria, or enlargement by the knife. 

Should the abscess have a short and free outlet, the sac should 
be injected two or three times a week with tincture of iodine, at 
first in solution, afterwards pure ; or by solution of persulphate 
of iron, weakened by admixture with twice its bulk of water. 

In case of entrance of feces, air, or urine into the diseased part, 
a counter-opening should be made which will allow their free 
escape, and the part kept as clean as possible by injection of tepid 
water. Then the fecal or urinary fistula allowing the vicarious 
discharge should be cured by appropriate means. 



25 



CHAPTEE XXVIII. 

PELYIC HEMATOCELE. 

Definition and Synonymes. — Under this and the synonymous 
titles of retro-uterine hematocele, peri-uterine hematoma, and 
bloody tumor of the pelvis, has been described an accumulation 
of blood in the pelvic cavity either above or below the peritoneum. 

History. — Although an attempt has been made to prove that the 
ancients were cognizant of this affection, the proof of such a fact 
is not satisfactory. The earliest allusion made to it is contained 
in the works of Euysch, of Amsterdam, who wrote in 1737. After 
this, little attention was paid to it until the time of Eecamier, 
although mention of it was made by Frank, Deneux, and some 
others. 

In 1831 Eecamier, under the impression that he was opening 
an abscess, cut into a tumor behind the uterus and gave exit to a 
large amount of black, grumous blood, and about ten years after- 
wards Bourdon, one of his pupils, published another case occur- 
ring in his practice. 

A tabular view of the names of those who have been chiefly 
instrumental in elucidating the subject and systematizing our 
knowledge upon it is here presented : — 

Recamier, 1831, " Lancette Franchise ;" 

Velpeau, 1843, " Recherches sur les Cavites Closes ;" 

Bernutz, 1848, " Archives de Medecine ;" 

Vigues, 1850, " Des Tameurs Sanguines de PExeav. Pelvienne ;" 

Nelaton, 1851, " Gazette des Hopitaux ;" 

Nonat, 1851, Theses de Cestan, Gallardo, et Prost ; 

Huguier, 1851, Lecture before Surgical Society of Paris ; 

Gallard, 1855, " Union Medicale ;" 

Voisin, 1858, " De PHematocele Retro-Uterine." 

I have not endeavored to record the names of all who have 
made valuable contributions in France, for had I done so the list 



PATHOLOGY. 387 

would have been a long one. Those only are referred to who 
have been foremost in advancing our knowledge. 

It will thus be seen that to France we are indebted for the early 
literature of pelvic hematocele. Germany has contributed little 
towards it. In Great Britain, Dr. Tilt was the first to publish 
upon it, and in America, Prof. Gunning S. Bedford reported the 
first case which I can find recorded. More recently, we are in- 
debted to Dr. Byrne, of Brooklyn, for a faithful report of several 
cases. Prior to the year 1851, although it had attracted some 
attention, it was not well understood even in France, for, in 1850, 
we find Malgaigne cutting into an hematocele under the impres- 
sion that he was enucleating a fibrous tumor, and losing his patient 
from hemorrhage. 

Pathology. — The definition of haematocele has no relation what- 
ever to the cause of the hemorrhage, which gives material for the 
bloody tumor. The disease consists in the collection of a mass 
of blood in the pelvis, above or below its roof, and, whatever 
be its source, such a collection constitutes the affection which en- 
gages us. Ordinarily, we find that the flow giving rise to it takes 
its origin from one of the three following sources : — 

1st. Direct escape of blood from vessels in or near the pelvis ; 

2d. Eeflux of blood from the uterus or tubes ; 

3d. Transudation of blood in consequence of dyscrasia. 
It is evident that haematocele is not a disease, but the symptom 
of a number of pathological conditions. As, however, the source 
of the hemorrhage which results in the bloody tumor very often 
cannot be ascertained, we are forced to deal with its most promi- 
nent and significant sign, taking this as an exponent of a state 
which is beyond the possibility of diagnosis. 

In works upon practice written twenty years ago, we find 
dropsy treated of as a disease. In those of to-day it is regarded 
only as a legitimate result of renal, cardiac, or hepatic disease. 
Obstetric writers, even as late as ten years ago, described puerpe- 
ral convulsions as a disease incident to parturition. Those writ- 
ing ten years hence will probably regard them, as many do to-day, 
as one of the numerous consequences of renal disease. We may 
with good reason hope that the time will come when a similar im- 
provement in description, based upon an advance in our know- 



388 PELVIC HEMATOCELE. 

ledge of pathology, may connect itself with hematocele, but at 
present etiology is often impossible. 

The special sources of the hemorrhage inducing the affection, 
which have been revealed by post-mortem examinations, may 
thus be presented at a glance. 

1. Rupture of bloodvessels in the pelvis. 

Utero-ovarian ; 

"Varicose veins of broad ligaments ; 

Aneurism of artery ; 

Vessels of extra-uterine ovisac. 

2. Rupture of pelvic viscera. 

Ovaries ; 
Fallopian tubes. 

3. Reflux of blood from the uterus. 

Eeflux of menstrual blood. 

4. Transudation from dyscrasia. 

Purpura ; 

Scorbutus ; 

Chlorosis. 
All of these causes have been proved by post-mortem research 
to have resulted in hematocele, but it cannot be questioned that 
rupture of any bloodvessel which empties its contents into the 
peritoneum might also do so. Blood poured into the peritoneum 
from rupture of the spleen, for example, would gravitate towards 
Douglas's cul-de-sac, because it is the most dependent portion of 
that membrane, and coagulating would give all the signs of a 
bloody tumor in that locality. At times the affection is indica- 
tive of serious internal lesion, rupture of the ovary or tube ; at 
others it results merely from imperviousness of the cervical or 
tubal canal, which prevents the advance of menstrual blood and 
causes it to regurgitate into the peritoneum ; while in still a third 
class of cases, it is created by pouring out of impoverished and 
diseased blood from the vessels of the peritoneum. The last con- 
dition has been described as hemorrhagic peritonitis. 

Whatever be the source of the blood, it collects either in the 
most dependent part of the peritoneum or in the pelvic areolar 
tissue beneath it. Here it remains for a time fluid, then under- 
goes partial coagulation, becoming a grumous mass like currant 
jelly, and lastly all the fluid being absorbed, a hard, resisting 
tumor composed of fibrinous material remains. Should the col- 



causes. 389 

lection have occurred in the peritoneum, its boundaries will be the 
walls of that cavity laterally and below, while a localized peri- 
tonitis forms for it a roof of effused lymph. If it collects in the 
areolar tissue of the pelvis, the effused blood will make its own 
nidus by percolating the loose structure and mechanically creat- 
ing a space in it. 

From either of these positions it is entirely absorbed, reduced to 
a hard, firm tumor, which remains for a long time, or is discharged 
by the vagina or rectum, or into the peritoneum. The last point of 
evacuation is fortunately rare. Nonat 1 quotes Dupuytren for this 
very ingenious and plausible explanation of the method of such 
absorption, which he likens to the process of digestion. The 
vessels of the cyst which are in contact with the mass remove its 
fluid portion, and thus its hard surface comes in apposition with 
the sac. This excites effusion of serum, which softens the fibri- 
nous wall and renders it susceptible of absorption, which soon 
occurs. Then again contact excites a flow of fluid, and again this 
is removed until the whole mass is diminished or completely ab- 
sorbed. 

Causes. — A glance at the recognized causes of the disease will 
make it evident that congestion of the pelvic organs must, in an 
eminent degree, predispose to it. This explains the fact that it 
has been found most frequently to have occurred during the 
period of uterine activity and especially during a menstrual epoch. 
The predisposing causes are — 

The period of uterine activity, 15 to 45 ; 

Disordered blood state, plethora or anemia ; 

The menstrual epoch ; 

Chronic uterine or ovarian disease ; 

The hemorrhagic diathesis. 
The exciting causes are — 

Sudden checking of menstrual flow ; 

Blows or falls ; 

Excessive or intemperate coition ; 

Obstruction of cervical canal ; 

Obstruction of Fallopian tubes ; 

Violent efforts ; 

Diseases impoverishing the blood ; 

1 Op. cit., p. 344. 



390 PELVIC HEMATOCELE. 

Varieties. — There are two forms of the affection, subperitoneal 
and peritoneal, which are represented by Figs. 153 and 154. 

Fig. 153. 




Subperitoneal hsematocele. (Simpson.) 
Fig. 154. 



Peritoneal haematocele. 



SYMPTOMS. 391 

The validity of the former has been denied by Aran, Voisin, 
and others, but reports of autopsies substantiating it, by Simpson, 
Nonat, and others, place it beyond doubt. Who, for example, 
can question such autopsic notes, as the following by Prof. Simp- 
son, 1 explanatory of the case represented in Fig. 153. " On dissec- 
tion I found the reflection of the peritoneum between the uterus 
and rectum raised up, as shown in this diagram, and a large mass 
of broken coagula of blood formed the tumor, having been extra- 
vasated behind the peritoneum forming the posterior covering of 
the broad ligaments, and, as it accumulated, having separated and 
pushed before it that portion of peritoneum and the utero-rectal 
fold of this membrane." Of the two varieties the peritoneal is 
probably the more frequent, at the same time that it is by far the 
more grave. 

Symptoms. — The absolute occurrence of hemorrhage is gener- 
ally preceded by symptoms which are premonitory, as fixed, dull 
pain over the ovaries, derangement of menstruation, metrorrha- 
gia, or prolongation of the menstrual discharge. The symptoms 
of the actual escape of blood will depend in great degree upon 
the nature and gravity of the accident which has given rise to it. 
Sometimes the affection occurs without any violent symptoms 
and almost without warning. It will be appreciated that this 
would be so if it were due to gradual reflux of blood on account of 
constricted cervix, or transudation, the result of purpura. Gene- 
rally a sudden manifestation of symptoms occurs, and the accident 
is announced as rapidly as is cerebral apoplexy. 
Most prominent among the symptoms are — 

Severe pain in the pelvis ; 

Faintness and coldness of extremities ; 

Nausea and vomiting ; 

Metrorrhagia ; 

Uterine tenesmus ; 

Tympanites ; 

Interference with bladder and rectum ; 

Febrile reaction. 
The patient feels as if a large and heavy body exists in the 
pelvis, and instinctively strives to expel it by the vagina. At 

1 Simpson on Diseases of Women, p. 262. 



392 PELVIC HEMATOCELE. 

times the pain complained of is very acute ; at others it is a dull 
and heavy aching. These symptoms abate in severity in a few 
days and are replaced by — 

Great exhaustion and feebleness ; 

Extreme paleness ; 

Tendency to chilliness ; 

Constipation ; 

Suppression of urine ; 

Great tympanites ; 

Apyrexia. 
All these symptoms point to two facts : 1st, sudden and exces- 
sive loss of blood; 2d, the existence of some substance in the 
pelvis which mechanically interferes with its viscera. A part of 
them might be produced by menorrhagia, a part by sudden retro- 
version ; but a union of the whole will strongly excite suspicion 
of hematocele and call for a physical exploration. 

Physical Signs. — Yaginal touch reveals a tumor, which is gene- 
rally posterior to the vagina, and which to a greater or less extent 
closes that canal. This is generally very marked, especially in 
the subperitoneal form of the disease, but sometimes, to detect 
the tumor, the finger must be carried into the fornix vaginas. 
The mass thus felt, if the examination be made within a day or 
two after its formation, will be found to be soft, smooth, and ob- 
scurely fluctuating. If a number of days have elapsed before it 
be touched, it will give the impression of irregularity, due to 
coagula surrounded by fluid blood. The uterus will be found 
pressed out of its position, generally upwards and forwards, so 
that the cervix will be above the symphysis. Sometimes, how- 
ever, it is forced out of the median line to one side. 

JSTonat 1 dogmatically announces that the uterus is never found 
between the tumor and the rectum, that is to say, behind the 
mass of blood ; but Chassaignac 2 reports a case in which the san- 
guineous collection existed entirely between the bladder and 
uterus, and consequently must have forced that organ backwards. 
Eectal touch will merely show that the bowel is closed by 
pressure from the tumor. 

1 Op. cit., p. 342. 

2 Courty, Mai. de l'Uterus, p. 912. 



DIFFERENTIATION. 393 

Abdominal palpation will reveal the presence of a hard mass 
which may extend only up to the superior strait, or as high 
as the navel. In cases where a small quantity of blood has been 
effused, and more especially where this has collected under and 
not in the peritoneum, an abdominal tumor may not be dis- 
covered. 

By the aid of conjoined manipulation the shape, extent, and 
character of the mass may be further ascertained. 

Differentiation. — The diseases with which hematocele may be 
confounded are — 

Pelvic cellulitis or abscess ; 
Eetroversion ; 
Extra-uterine pregnancy ; 
Fibrous tumor ; 
Dislocated ovarian cyst ; 
Cancerous deposit in pelvic tissue. 
Cellulitis and abscess generally follow parturition, present a 
tu^mor of small size, develop slowly and with signs of inflamma- 
tion, and become soft as they develop. The contrary is true in 
reference to hematocele. 

Eetroversion may present the signs due to the mechanical results 
of hematocele, but not those due to loss of blood. If pregnancy 
co-exist, conjoined manipulation will usually suffice for diag- 
nosis. If it should not, the uterine probe will elucidate the case. 
Extra-uterine pregnancy does not develop suddenly, but slowly, 
and is characterized by all the signs of pregnancy. In place of 
metrorrhagia there is amenorrhoea. 

Fibrous tumors grow slowly, are painless, and move with the 
uterus. They are irregular and hard. 

Displaced ovarian cysts are painless, show no signs of hemor- 
rhage, and cause no constitutional disturbance or metrorrhagia. 

Cancer in the pelvis is rare, and could hardly cause error of 
diagnosis. Its slow development, the absence of sudden and 
severe symptoms, absence of metrorrhagia, presence of cachexia, 
and general feebleness will serve as correct guides. 

It is always of great importance with reference both to prog- 
nosis and treatment to determine whether the case be one of peri- 
toneal or subperitoneal form. Differentiation may generally be 
made by the following comparison of symptoms : — 



394 PELVIC HEMATOCELE. 



PERITONEAL HEMATOCELE. 

Tumor high in pelvis and abdomen ; 
Constitutional disturbance very great ; 
Bladder and rectum often undisturbed ; 
Peritonitis marked ; 
Uterus pressed forwards or to one side ; 
Vagina not completely closed ; 
Vaginal mucous membrane of normal 
hue. 



SUBPERITONEAL HEMATOCELE. 

Tumor low and towards floor of pelvis ; 
Not so ; 

Bladder and rectum interfered with ; 
Not so ; 

Uterus elevated ; 
Vagina occluded ; 

Vaginal mucous membrane of violet 
color. 



Course, Duration, and Termination. — Hemorrhage from the 
sources enunciated as those of hematocele, may be so great as 
to destroy life immediately. Five such instances are recorded 
by Yoisin, and Ollivier d' Angers 1 mentions two in which death 
occurred in half an hour from rupture of a varicose utero-ovarian 
vein. Such a termination is, however, decidedly exceptional. 
The tumor generally disappears by absorption, is discharged by 
the rectum or vagina, or remains a hard, indurated mass for years 
afterwards. Discharge is most frequently followed by recovery, 
but sometimes putrefaction occurs in the walls of the sac, septicae- 
mia takes place, and death ensues. The process of absorption 
may be accomplished in three weeks, but six months may elapse 
before it is complete. 

Prognosis. — The prognosis is governed by the severity of the 
attack but in general is favorable. Death may result, but such an 
issue is rare. Of five cases with which I have met, one ended 
fatally from general peritonitis and four recovered. This propor- 
tion of deaths is large. Nonat out of fifteen cases lost but one. 
In cases of peritoneal form a graver prognosis is called for than 
in the subperitoneal, for evident reasons ; and where a great deal 
of blood has been lost the dangers are greater than where the 
amount has been more limited. This is true not only from the 
fact that an excessive flow might cause death from exhaustion, 
but because the removal of so large an amount of coagulum, 
whether by absorption or discharge, must necessarily expose the 
patient to great dangers. 

Complications. — The complications of the affection are — 

Peri-uterine cellulitis ; 

Pelvic peritonitis ; 

Displacement. 

1 Noeggerath, Bui. N. Y. Acad. Med., vol. i. p. 577. 



TEEATMENT. 395 

Results. — These complications, by leaving the uterus bound in 
a vicious attitude by false membranes, often induce as results, 
which may remain permanently — 

Dysmenorrhcea ; 

Sterility f 

Tendency to abortion. 

Treatment. — It will be rare that the physician will be called 
upon to resort to treatment before the amount of blood which is 
destined to be lost has collected in the pelvis. He will, however, 
often be present to witness the great constitutional disturbance 
and excessive prostration and pain which immediately follow the 
hemorrhage. The diagnosis being made, the indications of treat- 
ment will be simple enough : — 

1st. To check tendency to further loss ; 
2d. To prevent death from prostration ; 
3d. To relieve pain. 

To accomplish the first indication, perfect rest should be imme- 
diately secured. The clothes should be loosened, but no time spent 
in their removal, and the patient kept quiet upon the back. A 
bladder of ice, or cloths soaked in cold water, should be laid over 
the hypogastrium, and cold fluids given to drink if nausea should 
not exist as a symptom. 

In the fulfilment of the second indication, alcoholic stimulants 
and opiates should be freely used. Iced champagne or cold 
brandy and water should be given, and with them should be 
combined a solution of the sulphate of morphia or some fluid 
preparation of opium. In great nervous prostration, and more 
particularly when this has resulted from hemorrhage, opium 
proves a far more reliable and rapid stimulant than alcohol. In 
hematocele it is peculiarly applicable for the additional reason 
that it accomplishes at the same time the third indication, the 
relief of pain. 

Should pain be very severe or nausea exist, Magendie's solution 
of morphia should be injected hypodermically in the amount of 
ten minims, which may be repeated in twenty minutes if it fail 
to give relief. 

So soon as reaction has been fully established the attention of 

1 Courty, op. cit., p. 917. 



396 PELVIC HEMATOCELE. 

the practitioner should be turned to the decision of this important 
point, whether the accumulated blood should be evacuated or 
whether the case should be allowed to proceed without such inter- 
ference. 

Surgical Treatment. — Eecamier, in introducing the subject to the 
profession, inaugurated the practice of evacuating such tumors, 
and Nekton indorsed and popularized it. But experience taught 
Nelaton that the procedure was not judicious, and " to-day he 
proscribes it in an almost absolute manner." 1 Immediate surgical 
interference presses its claims in consideration of the facts that — 
1st. It is capable of cutting short a lengthy and dangerous dis- 
order ; 

2d. It may save the patient from the dangers incident to absorp- 
tion as well as discharge; 

3d. It removes from the peritoneum or pelvic cellular tissue a 
foreign body which, undisturbed, would prove the focus of in- 
flammation. 

It is not surprising that it was the favorite plan in the infancy 
of the subject. When, however, pathologists had had an oppor- 
tunity of studying the natural history of the affection it was as 
naturally superseded for the following reasons : — 

1st. It was discovered that, when not interfered with, haemato- 
cele very generally passes away rapidly. 

2d. It was discovered that the dangers of puncture were greater 
than those of the tumor left undisturbed. 

3d. Medical means were found to exert a marked controlling 
influence over its complications. 

Of course the special circumstances of each case must be the 
guide as to interference of this sort. In general terms all that 
can safely be stated is this : if great and prolonged pain threaten 
to exhaust the patient ; if the tumor be still fluid ; if, for any 
reason, rupture of a subperitoneal tumor into the peritoneum be 
threatened, and if the case be an unquestionable instance of the 
subperitoneal form, evacuation may be advantageously resorted to. 
Indeed, under such circumstances, a neglect of this means would 
be culpable. Without such indications it should be avoided, and 
reliance placed upon medical resources. 

1 Nonat, op. cit. 



MEDICAL TREATMENT. 397 

Methods of Operating. — The patient being placed upon the back, 
as if for lithotomy, a trocar and canula may be held in the right 
hand, guided to the most fluctuating and dependent part of the 
mass and plunged in. Or, the patient lying on the left side, the 
perineum and a part of the posterior vaginal wall may be lifted 
by Sims's speculum, and an incision made into the wall of the 
tumor by a tenotomy knife or small bistoury. Through the 
opening thus made, one or two fingers should be introduced and 
the clots removed. After evacuation by either method, the nozzle 
of a syringe should be introduced into the sac and a stream of 
tepid water, or of this with a very small amount of carbolic acid, 
should be very gently and cautiously made to wash out the 
cavity remaining. This should • be repeated once or twice in 
twenty-four hours, for prevention of septicaemia. 

Medical Treatment. — Keaction having taken place, perfect rest 
should be insisted upon. The patient should not rise from bed 
even for the calls of nature, the bladder being emptied by the 
catheter and the rectum by enemata, if necessary. Should the 
patient's strength permit of local abstraction of blood, leeches 
should be applied to the hypogastrium, and after their removal 
warm poultices of ground linseed should be constantly kept over 
the part. Pain should be quieted by opiates, and all the functions 
supervised. 

After the abatement of acute symptoms, a blister, four by six in- 
ches, should, unless some contra-indication exist, be applied over 
the hypogastrium, and this may with advantage be repeated every 
ten or twelve days. Its results will often be very marked, and 
although apparently harsh practice, it prevents much suffering, 
while it causes none. 

If the stomach is not much disordered, the iodide or bromide 
of potassium in moderate doses may be employed. Should any 
tendency to hectic fever show itself or a tonic be needed, quinine 
alone or combined with iron will serve an excellent purpose. 



CHAPTER XXIX. 

FIBEOUS TUMOES OF THE UTEEUS. 

Definition and Synonymes. — This affection consists in the de- 
velopment of hard, resisting, and generally globular masses in 
connection with the parenchyma of the uterus, with which they 
are identical in structure, except in the proportion of the elements 
forming them. Since the true nature of these growths has been 
understood, they have been described under the names of fibrous 
tumors, uterine fibroids, fibroma, and, more recently by Yirchow 
and Klob, myoma. 

History. — Until the time of Dr. William Hunter, who wrote 
towards the close of the eighteenth century, the true nature of 
uterine fibroids was not appreciated. They were confounded 
with malignant growths, of which they were regarded as a variety* 
He described them under the name of fleshy tubercle, and con- 
tributed greatly to the knowledge of their pathology ; but it was 
not until the writings of Chambon, 1 Baillie, Bayle, and others, 
that the subject was fully elucidated. Sir Charles Clarke, in 1814, 
wrote an excellent chapter upon them, which would almost 
answer the requirements of our day. 

Pathology. — Surprise that any confusion should have existed 
between these tumors and cancerous growths, will cease when the 
statement is made that that position is boldly assumed by so care- 
ful an observer as Dr. Ashwell, as late as 1844. He gives five 
reasons for his belief, which he declares appear to him "con- 
clusive." His reasoning has failed to convince others, no writer 
since his time having adopted the view which Dr. Hunter suc- 
ceeded in abolishing, and no fact in Gynecology is now more fully 
settled than that of the non-malignancy of these tumors. There 

1 Nonat, op. cit. 



PATHOLOGY. 399 

is another point in their pathology which is not so fully deter- 
mined ; that is the possibility of their undergoing cancerous de- 
generation. Bayle and Lobstein have declared that they never 
do so, and the researches of Cruveilhier and Lebert tend to sup- 
port the view; but Dr. Atlee, 1 of Philadelphia, and Prof. Simp- 
son, of Edinburgh, believe that malignant degeneration some- 
times occurs. If such alteration be possible, it is certainly ex- 
tremely rare, and is not an issue to be apprehended. 

Their number is almost unlimited, as is also their size. M. 
Courty reports one weighing fifty pounds, and Dupuytren another 
weighing twenty-five. I exhibited some years ago to the New 
York Pathological Society, the uterus of a negress which contained 
thirty five tumors of every size between that of a foetal head and 
that of a marble. 

Fibroids may develop in any part of the uterus ; but the usual 
site is in the body or fundus. Mr. S. Lee examined seventy-four 
preparations in the London museums, and found that the rarest 
of all locations for them is the cervix. A very interesting in- 
stance of a large tumor developed below the os internum is 
reported by Dr. Murray, in the sixth volume of the London Ob- 
stetrical Transactions. Their structure differs very greatly not 
only from their original development being different, but from 
their being susceptible of several diseased states, which will 
very soon be mentioned, and which produce their characteristic 
alterations. The typical form is that of hard, resisting fibrous 
tissue, which creaks under the knife. Under the microscope this 
is found to consist of long, fine fibres, generally united in 
bundles; of fusiform fibre cells analogous to fibro-plastic ele- 
ments ; and of round or elliptic granules of small size ; the whole 
being bound together by fine intercellular substance. This type 
is departed from by formation of cysts in the midst of the fibrous 
tissue, which constitutes the tumor one of fibro-cystic character. 
They are liable to a variety of diseases among which the most 
frequent are oedema, inflammation, fatty, colloid, and calcareous 
degeneration and apoplexy. The last consists in rupture of 
small bloodvessels within the mass, and consequent accumulation 
of blood. 

1 McClintock, Diseases of Women. 



400 



FIBROUS TUMORS OF THE UTERUS. 



Fig. 155. 



Very rarely the whole mass becomes a ball of calcareous 
matter, which projecting in utero, and becoming detached from 
its uterine attachment, is sometimes discharged per vaginam. 
This is the disease which was described by old writers as uterine 
calculus. The uterine attachment of fibroids of compound charac- 
ter is sometimes the seat of a species of varicose degeneration of 
the small vessels which causes the structure to resemble erectile 
tissue. Tumors thus affected have been styled by Yirchow, 
telangiectatic tumors. This vascular structure readily bleeds, and 
in one case I saw it the cause of a small hematocele. But large 
vessels are likewise discovered in the pedicles of fibroids ; Cail- 
lard reporting one the size of the radial artery. Klob has met 
with but one such vessel, which was the size of the uterine artery. 

Varieties. — Klob, whose excellent 
work on the " Pathological Anatomy 
of the Female Sexual Organs" has 
just been translated by Drs. Kammerer 
and Dawson, of this city, divides these 
growths into two classes — simple and 
compound. The first consists of one 
tumor, which is generally spherical, 
and which is connected by loose con- 
nective tissue with the uterus. The 
second is a compound tumor, made up 
of a number of small fibroids, con- 
nected by loose connective tissue. 
The second variety is more vascular 
than the first, and its surface is nodu- 
lated and not smooth. Both these 
classes present themselves clinically 
in three varieties which are created by the locality of the growths 
in the walls of the uterus. If they lie under the mucous 
membrane projecting into the uterus, they are called sub- 
mucous; if under the peritoneum, subserous; if in the wall of 
the uterus, interstitial. Figures 155, 156, and 157, represent 
these forms. 

If a tumor be situated in the wall of the uterus, it may remain 
there until it assumes large dimensions. Should it be near its 




Submucous fibroid. (Sims.) 



VARIETIES. 
Fig. 156. 



401 




Subserous fibroids. (Boivin and Duges.) 

mucous or serous lining, it is subjected to contractile efforts on 
the part of the surrounding parenchyma, which are excited by 
its presence, and which often in time force it towards the uterine 
or abdominal cavity. Sometimes its connection with the mother 
tissue is kept up by a broad base; 
sometimes it is limited to a long, Fig- 15 ?. 

slender pedicle, which, in the case 
of the subperitoneal varieties, al- 
lows of great mobility. Should 
the mass be forced into the uterine 
cavity, and gradually assume a 
slender, pedunculated attachment, 
it receives the name of fibrous 
polypus, which is therefore a 
variety of submucous fibroid. 

Subperitoneal uterine tumors 
have been known to perform the 
most singular migrations. The 
pedicle being broken, they have 
at times been found rolling about 

freely in the peritoneum, and at interstitial fibroid. 

26 




402 FIBROUS TUMORS OF THE UTERUS. 

others, having set up adhesive inflammation, they have been found 
detached from the uterus, and attached to some other abdominal 
viscus. 

Causes. — The predisposing causes, or rather those generally 
regarded as such, are — 

Eace, the African being peculiarly liable ; 

Age, from thirty to forty- five ; 

Sterility ; 

Menstrual disorders of long standing. 
Concerning the excitiug causes, one writing in the year 1866 
may, unfortunately, quote the words of Sir Charles Clarke, re- 
corded in 1814 : " Nothing is known respecting the cause of this 
disease." Fifty-two years of research have thrown no light upon 
its etiology. 

Complications. — The most frequent of the complications which 
show themselves in the course of the disease are — 

Endometritis ; 

Displacement ; 

Cystitis ; 

Obstruction of the rectum ; 

Haemorrhoids ; 

Pelvic peritonitis. 
Symptoms. — This enumeration of complications is a sufficient 
explanation of the great number of rational signs which present 
themselves, for not only do we meet with the symptoms of fibrous 
tumors, but with those of a variety of disorders which they 
excite. Most prominent among the symptoms are — 

Menorrhagia or metrorrhagia ; 

Irritability of bladder and rectum ; 

Pain throughout the pelvis ; 

Uterine tenesmus ; 

Profuse leucorrhoea; 

Dysmenorrhea ; 

Signs of pressure on crural nerves and vessels ; 

Watery discharge from uterus. 
These symptoms are not equally common to the three varieties 
of the affection. Subperitoneal tumors often, and interstitial 
tumors sometimes, are accompanied by none, or at least by very 



PHYSICAL SIGNS. 403 

few of them. It is the submucous variety which most constantly 
and prominently develops them. 

Physical Signs. — Although the rational signs are so numerous 
and striking, they can never do more than excite a suspicion, which 
leads to investigation by physical means. 

In the case of a large tumor no difficulty in diagnosis will pre- 
sent itself; for the results of vaginal touch, abdominal palpation, 
and conjoined manipulation will be so decided as to settle the 
character of the case definitively. When, however, a growth of 
small size exists, great difficulties will often attend diagnosis, 
which may be delayed until the case has been under observation 
for a long time. A thorough examination involves full and 
careful exploration, by touch, of the anterior and posterior sur- 
faces of the uterus, as well as of its cavity to the fundus. 

To examine the posterior wall the patient should lie upon the 
back. The examiner then depressing the uterus powerfully by 
one hand placed over the hypogastrium, should sweep the index 
finger of the other over that wall, first by the vaginal and then 
by the rectal touch. While the finger is lying under the uterus, 
in the vagina or rectum, the fingers of the hand on the abdomen 
should be made to depress its walls so as to sweep from the fundus 
over the anterior surface down to the cervix. The finger under 
the uterus lifting it up will offer itself as an opposing force to the 
hand on the abdomen. This manoeuvre will expose to examina- 
tion the outer surface of the uterus, unless the patient be very fat. 
Should this be so, a tenaculum may be fastened in the cervix and 
the uterus drawn down by it so that the posterior wall will be 
within reach of rectal touch, and the anterior wall of vaginal ex- 
ploration when the finger is pressed firmly against the base of the 
bladder. 

For investigating the interior surface of the uterus the neck 
should be fully dilated by tents of sponge or sea tangle, and im- 
mediately upon their removal, the uterus being depressed as for 
examination of the outer surface, the finger should be carried up 
to the fundus. Even without dilatation the presence of sub- 
mucous tumors may often be detected by careful examination by 
the uterine probe, and the attachment of a tumor may thus be 
ascertained. 



404 FIBKOUS TRIORS OF THE UTEEUS. 

Differentiation. — The diseases which may be confounded with 
fibrous tumors are — 

Peri-uterine cellulitis or abscess ; 
Pelvic hematocele ; 
Anteflexion or retroflexion ; 
Ovarian tumors ; 
Fecal impaction. 

The tumor created by cellulitis is always immovable, very 
sensitive, accompanied by fever, comes on suddenly, and fixes the 
uterus. A fibrous tumor is the opposite of this in every respect. 

Hematocele occurs suddenly with violent symptoms, sensitive, 
immovable tumor, at first semifluid, and accompanied by tympa- 
nites. Fibrous tumors show no such symptoms. 

Flexion may be determined by the uterine probe, and differen- 
tiation established between it and fibroids by conjoined manipula- 
tion and rectal touch. 

Ovarian tumors of solid form are the only ones which usually 
give difficulty in diagnosis. They are unaccompanied by me- 
norrhagia, can be pushed from side to side without affecting the 
position of the uterus as ascertained by vaginal touch, and are 
not themselves affected by movement of the uterus by means of 
the uterine sound. In cases where an ovarian tumor is firmly 
attached to the uterus, differentiation is not only difficult but often 
impossible. 

Fecal impaction offers a tumor which can be indented by pres- 
sure, is generally in the caput coli, does not move with the uterus, 
gives severe intestinal pain and disorder, and exerts no influence 
on the functions of the uterus. 

Prognosis. — The practitioner cannot be too cautious or display 
too much reticence in pronouncing the prognosis of uterine fibroids. 
There are few diseases in which the young physician will be led 
into greater error or be made to regret more decidedly an over- 
confident prediction. Fibrous tumors, unless of great size, rarely 
end fatally, however gloomy the prospect may appear when they 
are first discovered. And yet death from them is not so infre- 
quent as to warrant an entirely favorable prognosis. 

Frequency. — These facts are to a certain degree corroborated by 
an examination into their frequency. Were they as dangerous 
as is sometimes supposed, a large number of deaths would be 






COURSE, DURATION", AND TERMINATION. 405 

annually produced by them, for, to use the words of McClintock, 
" without question the most frequent organic disease of the uterus, 
if we except inflammation and its effects, is fibrous tumor." Bayle 
estimated that of all women dying beyond thirty-five years of age, 
twenty per cent, were thus affected. Even supposing that his 
assumption was an exaggerated one, an idea of the frequency of 
the affection may be gathered from the fact of his venturing 
upon it. 

Course, Duration, and Termination. — As already stated, these 
growths may attain the enormous weight of fifty pounds. Fortu- 
nately they very rarely reach such dimensions, but even when they 
do not they frequently exhaust the patient by metrorrhagia, leu- 
corrhoea, hydrorrhoea, and a low grade of constitutional irritation, 
often attended by hectic fever. But this termination, like the 
preceding, is exceptional. Having attained a moderate size they 
generally remain stationary, or increase slowly until the meno- 
pause, creating considerable inconvenience and depreciating the 
patient's strength by hemorrhage. Then undergoing a certain 
degree of atrophy with the cessation of uterine and ovarian func- 
tions, they cease to be, to any great degree, a source of annoyance, 
or at least of danger. Even during the age of uterine activity, 
nature may, unaided, effect a cure by the following means : — 

Absorption or atrophy ; 

Direct expulsion by rupture of attachment ; 

Sloughing from deprivation of nutrition, or inflammation ; 

Calcareous degeneration. 
The tumor is sometimes deprived of nutrition by inflammatory 
action occurring in the vascular structure of the uterine attach- 
ment which has just been described, collections of pus being 
sometimes discovered in it. 

Sometimes fluid collections take place within these masses, 
some morbid process destroying their tissue as if by liquefaction. 
The fluid thus collecting may be purulent, watery, or sanguine- 
ous. One of the most interesting of these instances is recorded 
by Dr. Sims, and represented by Fig. 158. Sims's view, that the 
growth was fibro-cystic, appears to me to be doubtful, though 
there is a difference of opinion with reference to these collections 
within fibroids. 

He describes it thus: "I passed a trocar into it at its lowest 



406 



FIBROUS TUMORS OF THE UTERUS. 



point, and in the direction of its long axis, and there were dis- 
charged more than twenty ounces of a colored serum. The punc- 
ture was enlarged for two inches, to prevent its closing. There 
was at once a sensible diminution in the size and tension of the 



Fig. 158. 




Submucous fibroid. (Sims.) 



abdomen. The discharge kept up for some time ; and this, 
together with occasional injections into the very fundus of the 
uterus, with the liquor ferri persulphatis, diluted with three or 
four parts of water, arrested very promptly the hemorrhages, and 
the patient was dismissed in two months in a very comfortable 
condition, and with strength enough to walk six or eight miles." 

Palliative Treatment. — In the vast majority of cases the efforts 
of the practitioner are limited to palliation of the evils resulting 
from the growth. Mechanical interference is prevented by an 
abdominal supporter and a pessary ; menorrhagia and leucorrhcea 
by astringent injections into the vagina and uterus; and pain by 
opiates and rest. Surgical means should be resorted to only 
under two circumstances : 1st, where the growth is so located as 
to render removal easy and safe ; 2d, where the disease is threat- 
ening the patient's life. 

Curative Treatment — In the removal of these growths the practi- 
tioner imitates the processes by which nature accomplishes a cure. 
Bringing to his aid the first three of her methods which have 



EXCISION. 407 

been mentioned, he adds to them others which she never de- 
velops. 

Uterine fibroids, whether submucous, subperitoneal, or inter- 
stitial, may frequently be removed by the following means : — 

Absorption ; 

Excision ; 

£crasement ; 

Enucleation ; 

Sloughing ; 

Gastrotomy. 
Absorption. — "Whether their absorption can be excited by any 
medicines at our command is very doubtful. Tumors have in 
certain instances been known to disappear while drugs have been 
employed, and perhaps they did so in consequence of their use. 
But no such effect can be looked for with any confidence. Indeed, 
with our present experience, such a result must be regarded as 
decidedly exceptional. Scanzoni, 1 after advising those medicines 
which are most popular as stimulants of absorption, says, " We do 
not remember a single case in which, with the means indicated, 
or with others, we have obtained the complete cure of a fibrous 
body." Whatever drugs be tried for this purpose should be con- 
tinued for many months, and even a year or two, before the trial 
can be considered fairly made, for their action is never immediate. 
Those in greatest esteem are iodine, the iodide and bromide of 
potassium, and the waters of certain mineral springs, as Kreuz- 
nach, Kissingen, Krankenheil, &c. All these may be employed 
externally in the form of hip baths as well as internally. 

In the case of small submucous tumors absorption is sometimes 
effected by pressure from the foetus in utero, and the same result 
is attainable by systematic pressure by tents of sponge or sea 
tangle. Thus far very few successes have been reported, but the 
plan certainly promises good results, and is worthy of trial. 

Excision. — Should a small submucous fibroid project into the 
uterine cavity, it may be removed by the severance of its attach- 
ment, by means of the knife, scissors, or other cutting instrument. 
If it be within reach of the knife or scissors, after dilatation of 
the cervix by tents, it may be removed by them. In case it be 

1 Op. cit. 



408 



FIBROUS TUMORS OF THE UTERUS. 



attached higher in the uterine cavity, the polyptome of Aveling 
may be made to answer a good purpose (Fig. 159). 

Fig. 159. 




Aveling's polyptome 

Eemoval may likewise be accomplished by the forceps of Nek- 
ton, represented in Fig. 160. 

Fig. 160. 




Nelaton's forceps. (Wieland and Dubrisay.) 

This method of removal is, however, much more applicable to 
those fibrous growths, which instead of preserving extensive con- 
nection with the uterus and coming under the head of tumors, 
have only an attachment by a pedicle and are therefore classed 
with polypi. 

Ecrasement. — Under almost all circumstances where excision 
may be practised, ecrasement becomes possible and should always 
be preferred. The operation consists in cutting off the mass, as 

Fig. 161. 




The ecraseur, straight and curved. 

near its attachment as possible, by the ecraseur. This instrument, 
the invention of M. Chassaignac, of Paris, consists of a flattened 



ECEASEMENT, 



409 



tube of steel which has two rods of the same metal passing through 
it to its upper extremity (Fig. 161). 

To the end of each of these the extremity of a chain is attached. 
This is passed around the part to be cut off, and the rods are re- 
tracted by a ratchet movement at the other extremity. Steadily 
and slowly the chain tightens around the mass and cuts its way 
through it. The ecraseur not only presents the great advantage 
of preventing hemorrhage, but experience proves that after its 
use inflammatory action is much less likely to occur than after 
that of cutting instruments. Should the tumor be small and have 
passed out of the uterus into the vagina, the chain of the ecraseur 
may be passed over it as a noose, by the fingers. If it be small 
and in the cavity of the uterus, the chain may be passed by means 
of the porte-chaine attachment of Sims, represented in Figs. 162 and 
163, which enables the operator by the aid of delicate arms extend- 
ing beyond the ecraseur to spread it out to the greatest extent. 

Fig. 162. 




w^ 



The arms of Sims's porte-chaine. (Sims.) 

Tiemann & Co. have constructed a simpler instrument in which 
the chain is passed by the limbs of the ecraseur which are elastic, 

Fig. 163. 




Sims's porte-chaine ready for encircling a tumor. (Sims.) 

and Dr. Emmet has improved this by making joints near the end 
of the instrument, as represented in Fig. 164. 



410 FIBROUS TUMORS OF THE UTERUS, 

Fig. 164. 




Ecraseur with joints and elastic arms. 
Fig. 165. 



Gooch's canulae armed with a ligature. 



But if the tumor be of great size, whether in the vagina or 
uterus, it may be necessary first to pass a cord around it by means 
of canulae, and in this way to draw in place the chain, which 
may be subsequently attached to the ecraseur, as represented in 
Fig. 166. 



Fig. 166. 




Fig. 167. 




A tumor encircled by Gooch's canula?. 



The ecraseur at work. 



ENUCLEATION". 411 

Sometimes the growth to be removed is so large that the chain 
of the ecraseur is too short to encompass it, under which circum- 
stances it may be replaced by a number of small wires called a 
wire rope, by a single large wire, or by a strong cord. 

Should the tumor be very large and fill the vagina completely, 
there are two methods by which it may be entirely removed: 1st, 
it may be drawn down by obstetric forceps and delivered ; 2d, it 
may be cut away, piece by piece, until its base be reached. By 
the first plan the uterus is temporarily inverted, the morbid 
growth removed by the knife, scissors, or ecraseur, and the uterus 
replaced, after the stump, should it bleed, has been seared by the 
white-hot iron. This process was first advised and practised by 
Desault and Herbineaux. Prof. Isaac E. Taylor, of this city, has 
several times resorted to it, and in one case I thus succeeded in 
removing a very large growth. The second plan is best carried 
out by the aid of the ecraseur. As much of the tumor as can be 
secured is seized in the chain and removed. Then another por- 
tion is engaged, and so on until a great part or the whole of the 
mass is cut away. 

Enucleation. — Excision is applicable to small submucous 
growths near the cervix, and ecrasement is only practicable when 
the attachment of the tumor is smaller than its body, and thus 
affords a surface for the support of the chain. Where neither of 
these conditions exists, or where the tumor is interstitial, resort 
must be had to other means. It has been stated that the attach- 
ment of submucous and even interstitial neoplasms to the uterine 
wall is not firm, they being surrounded by a layer of loose cel- 
lular tissue. This fact suggested many years ago, to the mind 
of Yelpeau, the possibility of enucleating them, and in 1810 M. 
Amussat put the theory into practice. Since that time the ope- 
ration has been resorted to by many surgeons, among the most 
successful of whom may be mentioned Dr. Atlee, of Philadelphia. 
A sufficient number of favorable results have been due to it to 
render it a warrantable procedure ; but it is unquestionably one 
attended by great hazard, as it may be destructive to life by 
inducing exhaustion, hemorrhage, perforation of the uterus, 
pyaemia, or inflammation of the pelvic viscera. Dr. West reports 
twenty-eight cases in which it was performed, fourteen of which 



~^2 FIBROUS TUMORS j I THZ 7717.75. 

proved fatal. Prof. Fordyce Barker, :: tins city, has once per- 
formed the operation with complete success :pon a large growth. 

"Peritonitis, phlebitis, and pyaemia, ' 7 says Dr. West, 1 in esti- 
mating the prospects of success held out by enucleation, "the 
consequences of violence done to the uterus of women exhausted 
bv large and frequently repeated floodings, are dangers from 
which but few have altogether escaped ; under which I fear that 
correct statistics will show that most have succumbed/' But the 
great "angers attending its rerformance should not deter the 
surgeon from resort to it in cases suited to it, and absolutely re- 
quiring aid. They should merely induce him to exhaust all 
palliative means before resorting to this, which should be looked 
upon in large tumors, as a last resource. 

The steps :: the operation are as follows : — 

1st Tie cervix should be fully dilated by tents, or freely 
incised in two or three places, as practised by Dupuytren, Amus- 
5:7. ker Br:~:i. 

2d. After disappearance of the results of incision, should this 
have been resorted to, the vagina being dilated by Sims's specu- 
lum, and the tumor held firmly by tooth forceps, an incision is 
made :~e: its surface and through its capsule. This nay be 
either straight :; :: ;:ial. 

3d. The fingers or a blunt instrument being passed into the 
opening thus made is swept around the mass, so as to sever its 
attachments and turn it out of its bed. At the same time i: is 
lifted from below upwards by the forceps. If the mass be re- 
moved, all clots should be washed out of the uterus by a stream 
of water, and the patient quieted by full doses of opium. 

Sometimes a middle course may be followed with advantage 
in such a case as that represented in Fig. 163, for example. The 
os being dilated or incised, a long crucial incision is made over 
the presenting part of the tumor, and the lips of the capsule 
separated by the finger, in the hope that the body of the tumor 
may present through this species ■: : and be expelled by 

uterine efforts. A most interesting case in which this occurred, 
is recorded by Dr. Grimsdale, in the Liverpool Med. and Surg. 
Journal for January. 1557. 

1 L'i = . 77:^_-i. "Z'z. -i - . : '. 



GASTEOTOMY, 



413 



Fig. 168. 



Sloughing. — Mr. I. Baker Brown, of London, has proposed in 
imitation of a process sometimes naturally set np in fibroids, to 
create the tendency to sloughing by cutting a deep, circular hole 
in them and filling this with oiled lint. This he has styled 
gouging, and reports a number of cases successfully treated by 
the plan. We are informed by Dr. Sims 1 in his recent work, 
however, that " Mr. Baker Brown does not now mutilate the 
fibroid, but satisfies himself with simply incising the os and 
cervix uteri." 

The dangers which must result from the presence of a large 
sloughing mass in the uterus are manifest, but it is equally so 
that in such a case as that represented in Fig. 168, it may become 
necessary to incur the attending risks rather than allow the 
patient to die from the continuance of the disease. 

Gastrotomy. — Subperitoneal tumors are much less amenable to 
surgical treatment than those 
which are submucous, but in com- 
pensation they are less injurious 
in their results. In some cases, 
however, they excite so many 
evil symptoms as to call for re- 
moval — and this has been effected 
by incision through the abdomi- 
nal walls. The operation is truly 
a formidable one, and yet, since 
it has been repeatedly successful 
in cases susceptible of no other 
means of relief, it is worthy of 
consideration. Indeed, should 
the steady decadence of the pa- 
tient's strength make it certain 
that a fatal issue must soon ensue, 
the operation in the case of a pe- 
dunculated subperitoneal tumor 
would become a matter of duty, and not remain one of choice. 

The prospects of success from it will depend very much upon 




Submucous fib 



Dubrisay.) 



Op. cit., p. 121. 



414: FIBROUS TUMORS OF THE UTERUS. 

the character of the attachment of the tumor to the uterus and 
other viscera of the abdomen. Unfortunately the extent of these 
cannot be accurately ascertained before abdominal section and 
investigation by touch, which of itself involves risk. This is by 
no means so considerable as would at first be supposed, and where 
doubt exists it should be resorted to. Dr. John Clay reports 
twenty-three instances in which it was adopted. Of these, sixteen 
recovered, three died, and of four no account was given in the 
reports. 

With reference to the propriety of the operation of gastrotomy 
for removal of uterine fibroids the opinion of the mass of the 
profession is at present determinedly adverse. And yet it is not 
more so than it was twenty years ago with reference to ovariotomy. 
It is highly probable that when experience has rendered the ope- 
ration safer than at present it will be resorted to for the same 
reasons which to-day cause us to perform extirpation of the ova- 
rian sac, and be regarded, as that operation is, as a practicable 
and expedient procedure. Not only is this opinion sustained by 
recent statistics, it is foreshadowed in the modified opinions ex- 
pressed by late writers. M. Courty, after stating the unfavora- 
ble results of the operation and the adverse impression concerning 
it left by them, goes on to add: "But recent operations tend to 
modify our opinion on this point as they have done upon ovario- 
tomy." 1 In saying this he appears to have anticipated what 
the future will bring forth. It is true that thus far statistical 
evidence does not favor it, but Prof. Storer declares, "that the 
mortality of the earlier uterine extirpations was no greater than 
that in many isolated groups of the other operation." 

It is not venturing too much even now to say that if the fibroid 
is pedunculated and unattached, its removal is no more dangerous 
than the ordinary operation of ovariotomy. If it be completely 
amalgamated with the uterus, or so bound to neighboring parts 
that removal proves very difficult, the operation may be aban- 
doned, the patient having, without great risk, availed herself of 
every chance of cure. But even if the removal of the neoplasm 
involves that of the uterus and ovaries, We may hope for twenty - 

1 Op. cit., p. 977. 



GASTEOTOMY. 415 

five per cent, of recoveries, as the following table, arranged by 
Prof. H. E. Storer, 1 will prove : — 

Operations. Deaths. 

Clay 3 2 

Heath 1 1 

Bnraham 9 7 

Kimball 3 2 

Parkman ......... 1 1 

Peaslee 1 1 

Koeberle 1 

Baker Brown 1 1 

Wells 1 1 

Sands 1 1 

Buckingham 1 1 

Storer 1 

24 18 

Percentage of recoveries 1 in 4, or 25 per cent. 

In a private communication Prof. Storer informs me that he 
has now removed the entire uterus by gastrotomy five times, and 
has lost four of his patients. 

No operator should undertake gastrotomy for uterine neoplasms 
without being prepared, if necessary, to remove the uterus with 
the tumor, for sometimes the connection is so intimate that an 
iexact localization of the tumor is out of the power of the most 
skilful diagnostician. Indeed, after removal of the mass from 
the body, its relations to the uterus are often discovered only 
after patient and intelligent search. Dr. Farre tells of a case 
preserved in one of the London museums as a solid ovarian tumor 
which, upon careful examination, he proved to be uterine by 
tracing the Fallopian tubes into it. It was also in this way that 
the nature of the tumor removed by Dr. Storer was identified, 
Prof. Ellis, after very minute examination, distinctly discovering 
the entrance of the tubes into the cavity of the body and thus 
settling the matter. 

The operation is performed in exactly the same manner as 
ovariotomy, and for particulars concerning it the reader is re- 
ferred to the chapter describing that procedure. The accidents 

1 " On removal of the womb and both ovaries." The tumor which necessitated 
the operation weighed thirty-seven pounds, and was the largest ever extirpated. 



416 FIBKOUS TUMORS OF THE UTERUS. 

which have generally produced a fatal termination in cases of 
gastrotomy are as follows : — 

1st. Primary or secondary shock or collapse ; 

2d. Hemorrhage ; 

3d. Peritonitis ; 

4th. Septicaemia. 
As Prof. Storer points out, we have now arrived at means for 
limiting the first ; the improved methods of hsemostasis at our 
command diminish the danger of the second ; and the knowledge 
of the fact that carefully cleansing the peritoneum of blood and 
other fluids markedly diminishes the probability of the occur- 
rence of the third and fourth, will in future aid in avoiding them. 
I have endeavored to lay the facts connected with gastrotomy 
for uterine neoplasms before the reader in their true light, care- 
fully avoiding any partial or prejudiced representation concerning 
them. What position the future will assign to the operation no 
one can at present declare, but of this we may even now be sure, 
that they are culpably barring the way to advancement who refuse 
to attempt the only plan by which life may, at times, be saved, 
and screen themselves from blame in so doing by casting censure 
and reproach upon those who endeavor to afford the patient every 
chance for life. 

In some cases surgical means fail to effect removal, and are 
resorted to merely for palliation. Where a large submucous 
fibroid is producing exhausting hemorrhage an incision directly 
across its most dependent point, and others cutting the superficial 
layer of fibres of the os, will often control the flow to a great 
extent. This probably results from disgorging the habitually 
distended vessels of both tumor and uterus. 



CHAPTER XXX 



UTERINE POLYPI. 



Definition. — A uterine polypus is a tumor covered by the mucous 
membrane of the uterus and attached to that organ by a pedicle 
or stem. 

History. — While so many uterine disorders of greater obscurity 
are described by the earliest medical writers, this, the diagnosis 
of which is often so self evident and positive, attracted little 
attention. Hippocrates, Celsus, Gralen, and even Aetius make no 
mention of it. By Moschion it was described in the third century, 
and called pulps or polypus, but it was certainly neither well un- 
derstood nor treated in his time, and we get no clear accounts of 
it until the revival of this branch of learning by the French 
School in the seventeenth century. Then Gruillemeau, and subse- 
quently Levret, threw much light upon it, and in the latter part 
of the eighteenth and beginning of the nineteenth centuries many 
others contributed to place our knowledge upon its present basis. 
Varieties. — The student will meet with much difficulty in arriv- 
ing at definite ideas concerning the varieties of uterine polypi. 
Almost all authors differ in their classification, and the number 
of names which have at various times been applied to them is too 
large even for repetition. Let it be borne in mind that since these 
tumors are formed by excessive development of one of the tissues 
existing permanently or temporarily in the uterus, there are 
but four elements which can give rise to them : the parenchyma, 
the mucous membrane and cellular tissue, the glands of that 
membrane, or some foreign mass which is retained in the uterus. 
It is true that by some a species of vascular polypus formed from 
development of the bloodvessels, a species of telangiectasis, has 

kbeen described, but it is probable that this is only a form of the 
mucous variety. All classifications of these growths are to a great 



418 



UTERINE POLYPI. 



extent arbitrary, and hence in the present state of pathology 
none can become universal. That which I will adopt is this : — 

1st. Cellular polypi; 

2d. Glandular 

3d. Fibrous 

4th. Fibrinous " 

Each of these genera includes several species, the chief of which 
may thus be tabulated : — 
Cellular Polypi include, 

Fibro-cellular polypi ; 

Soft 

Mucous 

Vascular 

Cellulo- vascular 

Glandular Polypi include, 

Vesicular 

Cystic 

Channelled 

Tubular 
Fibrous Polypi include, 

Hard 

Muscular 

Fibro-cystic 
Fibrinous Polypi include, 

Sanguineous " 

These varieties are subject to morbid actions which create other 
forms, as, for example, fatty, calcareous, and malignant polypi. 
Colombat refers to a large, hollow polypus which, when removed, 
leads the operator at first to fear that he has mistaken an inverted 
uterus for a polypus. He states that Eicherand and Jules Cloquet 
were once thus deceived, until the subsequent death of the patient 
enabled them to correct their error by post-mortem inspection. 
Mme. Boivin represents one of this character as shown in Plate 19 
of her work. She calls it hollow polypus ; declares that before 
its removal by M. Dubois it was regarded as inversion by several 
physicians, and accounts for it by supposing that some plastic ele- 
ment had coated the uterus and been ripped off, except at its cer- 
vical attachment, and become inverted by menstrual fluid collect- 



PATHOLOGICAL ANATOMY, 



419 



ing above. Some months ago Dr. Henschel presented to the New 
York Obstetrical Society a hollow polypus which was attached 
to the cervix by three points. It was referred to Dr. Noeggerath 
for examination and report, and his method of accounting for it 
was similar to that of Mme. Boivin in the case just mentioned. 

Pathological Anatomy. — The cellular polypus is a tumor, gene- 
rally of pear shape, varying in size from a marble to a hen's egg. 
It is covered over by the mucous lining of the uterus, and consists 
within of cellular tissue in a state of hypertrophy or hypergenesis. 

Fig. 169. 




A cellular polypus with long pedicle. (Boivin and Duges ) 



Its attachment is generally, though not always, to the wall of the 
cervix, and in its structure appears a certain amount of cervical 



420 



UTERINE POLYPI. 



fibrous tissue. Sometimes the pedicle of this variety is very long 
and slender, so that it hangs outside of the vulva. Fig. 169 exactly 
represents one sent to me by Dr. Crane, of Elizabeth, N. J., for 
corroborative diagnosis, and which was afterwards removed by 
him. 

The glandular polypus consists in hypertrophy of the Nabothian 
glands or (according to Dr. Farre) of the utricular follicles. Seve- 
ral follicles are enlarged, and, being bound together by connective 
tissue, make up a tumor of pediculated form. It may arise either 
from the cervix or body, but very generally grows from the 
former, and is commonly gregarious. 



Fig. 170. 



Fig. 171. 





A cellular polypus attached within 
the cervix uteri. 



Glandular polypi. (Boiyin and Duges ) 



The fibrous polypus is a submucous fibroid, resembling closely 
those which are subserous and interstitial. Slowly extruded 
from contact with the uterine parenchyma by its contraction, 
the tumor gradually acquires a pedicle and gives us the form of 
polypus under consideration. Fibrous polypi usually arise 
from the body, though they are sometimes attached to the rim of 
the os. 



PATHOLOGICAL ANATOMY, 



421 




Fibrous polypus growing from fundus. (Clarke.) 
Fig. 173. 




Fibrous polypus growing from lip of cervix. (Sims.) 

About the very existence of the fibrinous polypus there is some 
doubt. Kiwisch regards it as due to a collection of blood in atero, 
the serous portion of which is absorbed and the fibrinous organ- 
ized. Scanzoni accepts this view, but regards the previous occur- 



422 UTEEINE POLYPI. 

rence of pregnancy as necessary to it, and supposes that the blood 
clot is attached to the placental site. The mass thus attached 
obtains vascular connection with the uterus and presents the ordi- 
nary features of polypi. 

Causes. — Any chronic inflammatory action, any obstruction to 
escape of menstrual blood which causes uterine tenesmus, or any 
influence tending to keep up uterine congestion, will predispose 
to hypergenesis of the elements of the mucous membrane. But 
as for fibroids, so for fibrous polypus, no cause is known. 

Symptoms. — Polypi excite two classes of symptoms, those due 
to their presence exciting mucous congestion, and those due to 
their acting as elements of obstruction to escape of menstrual 
blood. These two influences result in the following signs : — 

Leucorrhoea ; 

Pain in back and loins ; 

Menorrhagia ; 

Metrorrhagia ; 

Hydrorrhoea ; 

Sometimes dysmenorrhea. 
The last of these is not a frequent sign, but sometimes presents 
itself prominently, as it did in the following case which occurred 
before we understood the use of tents as we do at present. A 
lady came from a distance to put herself under Dr. Metcalfe's care 
for dysmenorrhea, characterized by severe tenesmus and expul- 
sion of clots. This had lasted for years, and resulted in emacia- 
tion, and great nervousness and irritability. In time she came 
under my care ; was treated by me for nearly a year, and went 
home unrelieved. At her next period she sent for the country 
physician in her neighborhood, who examined by touch, detected 
in the vagina a small polypus which hung by a stem from the ute- 
rus, and twisted it off to her complete and permanent relief. This 
had been at last expelled after having rested upon the os inter- 
num, and acted as a ball valve for years. The uterus had been 
repeatedly examined before, but nothing could be discovered. 

Physical Signs. — These will depend in great degree upon the 
size and location of the growth. Should it be in the cavity of 
the body and small, no signs will be afforded by the touch or 
speculum ; if, however, the body be explored by the probe, this 
will be found to be deflected by it. The cavity will be discovered 



TREATMENT. 423 

to be much congested, and a copious flow of blood will often follow 
the withdrawal of the instrument. Should the tumor be large, 
the body will in addition be found to be displaced, increased in 
size, and the cervix somewhat dilated. Should the attachment of 
the tumor be cervical, it can often be felt hanging from the canal 
or in the os uteri. But no examination for uterine polypi can 
be considered complete until the cervix has been fully dilated by 
tents, and careful exploration made by sight, touch, and the probe. 
Even then a number of attempts will often be requisite before 
small growths are detected. 

Differentiation. — Polypi must be differentiated from fibrous 
tumors even after the discovery of an intra-uterine growth has 
been made. The symptoms to which they give rise are very 
similar, and it is by physical means alone that differentiation can 
be effected. These means are the use of tents, the probe, and 
touch. By them, the mobility of the tumor, the point of its 
attachment, and the breadth of its base, may all be definitely 
determined. 

Course and Termination. — Nature may cure a uterine polypus by 
ejecting the mass with so much force as to fracture its attachment 
and disconnect it with the uterus, or calcification or sloughing 
may occur. But neither of these results can be looked for with 
any confidence. In the majority of instances, without surgical 
interference, steadily advancing anaemia will ultimately destroy 
life. 

Prognosis. — The prognosis is generally good, depending of 
course upon the possibility of removal. 

Complications. — They create but two complications, namely, 
endometritis, and chlorosis of very grave character. 

Treatment. — In the treatment of polypi, these two indications 
present themselves : first, to cause the expulsion of the growth 
from the uterus, and second, to accomplish its removal when 
thus expelled, by means which will presently be considered. 

To cause the extrusion of the growth from the uterus into the 
vagina, the cervix must first be opened by tents, or by slitting 
its walls, and then the uterus must be stimulated to contractions 
by systematic and prolonged use of ergot. If it be possible to 
grasp the polypus by forceps, it may be drawn out in that way. 



424 UTERINE POLYPI. 

The second indication may be accomplished by — 

Excision ; 

Torsion ; 

Ligature ; 

£crasement. 
Should the pedicle be within reach of knife or scissors, it may 
be clipped ; or if higher in the uterus, the polyptome may be 
employed. Should the growths be so small as not to be suscepti- 
ble of seizure, they may be scraped from their attachment by the 
curette ; and should they be small and possess slender pedicles, 
they may be seized with forceps and twisted off. The ligature, 
lately so popular, is now rarely employed ; the tardiness of its 
action, and the/etid discharge which it excites, rendering it objec- 
tionable and dangerous, ficrasement constitutes the safest and 
most expeditious of all the operations. Sometimes, however, great 
difficulty attends the encircling of the tumor by the chain of the 
instrument. To effect this, it is often necessary to encircle the 
mass first by means of a ligature passed by Gooch's canulae, and 
then to draw the chain into position by tying it to the end of this, 
as represented on page 410. 

Whenever it is practicable, all manipulation should be delayed 
until expulsion of the tumor into the vagina is obtained ; but, 
unfortunately, operative procedure is sometimes called for before 
this can be effected. Then the operator works to disadvantage, 
and the patient is exposed to great hazard. I have in more than 
one instance seen life destroyed by such efforts, even when 
cautiously conducted. 

ISTo sooner does the tumor escape into the vagina than the 
whole phase of the case is altered. Eemoval involves no danger- 
ous manipulation, and is simple and easy. For this reason it is 
advisable to use every effort to open the cervical canal and 
stimulate uterine action. Even if section of the cervix to the 
vaginal junction is needed, it would be safer to resort to it than 
to manipulate the tumor in utero. 

The directions for applying each of the means of removal re- 
commended are so fully given in the preceding chapter upon 
fibrous tumors, that, to avoid repetition, the reader is referred to 
it for details. 



CHAPTER XXXI. 



CANCER OF THE UTERUS. 



Malignant disease may affect the uterus in three forms : — 
Cancer ; 
Cancroid ; 
Epithelioma. 
The varieties of each may be presented at a glance by the fol- 
lowing table : — ■ 

Malignant diseases of the uterus. 
Cancer. 

Encephaloid ; 
Colloid ;(?) 
Scirrhus. 
Cancroid. 

Fibro-plastic ; 
Recurrent fibroid. 
Epithelioma. 

Corroding ulcer ; 
Cauliflower excrescence. 
Each of these will in turn engage our attention, the present 
chapter being devoted to cancer. 

Definition and Synonymes of Cancer of the Uterus. — This disease, 
which has been described under the synonymous terms of carci- 
noma uteri, and ulcerated carcinoma, may be defined as a degene- 
ration of the interstitial tissue of the uterus characterized by 
grave constitutional implication, great tendency to molecular 
death, and a certainty of reproduction if removed by surgical 
means. 

Frequency. — According to Rokitansky, 1 the following average 
scale may be adopted as representing the preference of cancer for 

1 Sydenham Trans., vol. i. p. 198, Am. ed. 



426 CANCER OF THE UTERUS. 

various organs. " First the uterus, the female breast, the stomach, 
the large intestine, and especially the rectum ; next comes cancer 
of the lymphatic glands," &c. The great frequency with which 
the uterus is thus affected, may be judged of by the statements 
of Prof. Simpson, based upon reports made under the Eegistra- 
tion Act, during a period of five years (from 1838 to 1842), for 
England, exclusive of London. 

Number of women who died of cancer . . . 8746 
" " " " " " " uteri . . 3000 

These statistics further prove that cancer is nearly three times 
more frequent in women than in men, and more than three times 
more frequently met with in the uterus than in any other organ 
of the female. 

History. — M. Becquerel asserts that, " in spite of its great fre- 
quency, cancer of the uterus is not a disease of which the history 
has been long known." That it was not understood as we under- 
stand it to-day, is most true ; but the ancients surely had a great 
deal of very accurate knowledge concerning it. Hippocrates — 
de Morbis Mulierum — describes it at length, declaring it to be in- 
curable. Archigenes wrote an able chapter upon it, describing 
the ulcerated and non-ulcerated forms and the peculiarities of the 
discharges. His article is preserved by Aetius, who entitles it 
"De Cancris Uteri," and is copied verbatim by Paul of iEgina 
without the slightest acknowledgment. The Arabians likewise 
were familiar with it, Alsaharavius, Haly Abbas, and Ehazes, all 
alluding to its prognosis and treatment in a manner which leads 
us to believe that they understood its true nature. 

Upon the revival of Gynecology in France, the disease was 
confounded with fibrous tumors and parenchymatous inflamma- 
tion, or rather with its resulting hypertrophy. Astruc described 
"schirrhus" as the result of- abortion, in 1766, and the confusion 
which attached to his description extended long after him. It 
characterized the times of Eecamier and Lisfranc, and even so late 
as our own period we see the view indorsed by Drs. Ashwell, 
Montgomery, Dnparcque, and many others. Messrs. B latin 1 and 
Nivet, in expressing their belief that scirrhus results from chronic 

' Mai. des Femmes, Paris, 1842. 



PATHOLOGY 



427 



inflammation of the parenchyma, append the following foot-note : 
" Paul of JEgina, Galen, Andral, Broussais, Breschet and Ferrus, 
Piorry, Bouillancl, &c, place scirrhus among the terminations of 
chronic inflammation; some of them, however, admit the exist- 
ence of a predispositions" 

For the proper differentiation of true malignant disease from 
neoplasms and the results of inflammation we are indebted to no 
one so much as to Dr. Henry Bennet, of London. 

Although there are many points connected with the subject 
which are still undecided, the following may be laid down as 
generally accepted truths : — 

1st. Cancer of the uterus bears no similarity to fibrous tumors, 
polypi, or parenchymatous engorgements ; 

2d. It arises from a constitutional vice, and is never the result 
of chronic inflammation or any other purely local cause ; 

3d. It is incurable, and if removed by surgical means will 
inevitably return. 

Pathology. — The affection probably originates in some peculiar 
blood state which we do not at present understand and which 
results in a local deposit of a morbid element. Eokitansky regards 
the abnormal condition of the blood as consisting mainly in a 
preponderance of albumen and a hypinosis or diminution of 
fibrine. Whatever be the peculiar state which gives rise to can- 
cerous deposit, it is certain that any form of the affection may 
arise from one and the same disorder. This is proved by the facts 
that several deposits of different varieties may coincidently exist, 
that one form may change into another, and 
that one being removed by surgical means 
a different one may replace it. 

Not only is the uterus most frequently 
selected as a site by the disease; the cer- 
vix is almost always the part of this organ 
primarily affected. In some cases the body 
is the original seat of the deposit, but this is 
extremely rare. 

I have met with but two cases of it. One, 
which is represented in Fig. 174, 1 saw with 
Prof. Charles A. Budd. The other is now can 
under the care of Dr. James L. Brown, with 




428 



CANCER OF THE UTERUS. 



whom I have had an opportunity of examining it after dilatation 
by sponge tents. 

The tissue usually first affected by deposit is the submucous r 
areolar tissue of the neck. From this point it spreads, invades the 
whole neck, and sometimes the body of the uterus, the ovaries, 
vagina, bladder, and intermediate tissue. Even the bones of the 
pelvis may be attacked. For a varying length of time the depo- 
sition goes on, then without assignable cause the lowly organized 
mass begins to die, and ulceration or molecular death occurs. 
The detritus gives rise to a fetid, ichorous, and bloody discharge, 
which excoriates the vulva and thighs and renders the patient 
disagreeable to herself and all around her. With greater or less 
rapidity the vital forces are sapped, and the patient succumbs ; 
not, however, in many cases, before the greater part of the uterus 
has been removed and the bladder and rectum opened into. 

Varieties. — Cancer may assume in the uterus any of its various 
forms. Scirrhus, or hard cancer, in which there is a preponderance 
of fibrous tissue ; colloid or gelatinous cancer, in which an abund- 
ance of fluid is combined with epithelial cells in alveolae or loculi ; 
and encephaloid, medullary, or soft cancer, in which epithelial 
hypergenesis preponderates over the other elements of the deposit. 




Scirrhus of anterior lip not ulcerated. (Boivin and Duges.) 

The first of these is rare. The vast majority of cases present 
the features of the encephaloid variety. As to the second or 



SYMPTOMS. 429 

colloid form of cancer, pathologists are rapidly altering their 
views, many not only doubting its true cancerous nature, but 
denying it entirely. 

Causes. — Those predisposing causes which are of undoubted 
authenticity may be thus enumerated : — 
Hereditary tendency ; 
Middle or advanced life ; 
Grief or other depressing mental influences ; 
Eepeated parturition ; 
Life in a large city ; 
Want of food, pure air, and exercise. 
Although cases have been reported at the extremes of woman- 
hood, it is generally admitted that few occur before twenty and 
after sixty. The most fruitful period is from 40 to 50 ; the next 
from 30 to 40 ; the next from 20 to 80 ; and the next from 50 
to 60. 

The exciting causes are entirely unknown. As has been already 
stated, the view entertained by many a few years ago, that cancer 
is often a result of chronic inflammation is now generally repudi- 
diated. In my own experience I have yet to find a case even 
remotely sustaining such a position. 

Symptoms. — The disease may pass through its period of incep- 
tion and make considerable progress towards a fatal issue with- 
out developing any symptoms which attract the attention of the 
patient. Or only slight leucorrhoea and hemorrhage may exist, 
which may have been passed over as trivial circumstances, not 
deserving treatment or investigation ; but this is decidedly excep- 
tional. Usually the following symptoms develop themselves and 
become more and more prominent as destruction of the exudation 
advances : — 

Pain through the pelvis ; 

Tenderness upon movement or coition ; 

Menorrhagia and metrorrhagia ; 

Ichorous and fetid leucorrhoea ; 

Hydrorrhcea ; 

Dark, grumous discharge ; 

Constitutional debility ; 

Pallor and cachectic facies ; 

Yesico-vaginal or recto-vaginal fistulas. 



430 CANCER OF THE UTERUS. 

Pain and tenderness are not nearly so constant or severe as is 
often supposed, and they may both be entirely absent. 

Menorrhagia and metrorrhagia may exist even before ulcera- 
tion has occurred, resulting then from congestion of the mucous 
membrane. But it is not until after the inauguration of the pro- 
cess of destruction that they become alarming or excessive. 

Ichorous, watery, and grumous discharges very generally mark 
the advance of the disease. The first of these discharges produces 
erythema, erosions, vaginitis, and often a strong sexual appetite. 
The second exhausts the patient by draughts made upon the serum 
of the blood. The third creates fetor, and sometimes results in 
septicaemia, for the material giving color and odor to the flow is 
a putrilage formed by the detritus of the decaying uterus. 

Constitutional debility and cachectic facies are the results, in 
part, of the malignant toxaemia which is the basis of the disorder, 
in part of exhaustion produced by loss of blood or some of its 
elements. Should the walls of the rectum and bladder become 
implicated, as they very often do, the functions of these viscera 
are deranged, and the feces or urine, or both, pour out through 
the vagina, increasing the misery of the patient. 

Physical Signs. — Suspicion is generally first aroused and physi- 
cal exploration prompted by these three symptoms, menorrhagia, 
fetid discharge, and ichorous leucorrhcea. They belong to the 
second or ulcerative stage of the affection, and, as Dr. Henry 
Bennet has well established, it is almost invariably in this stage 
that the physician is consulted. Before it no symptom generally 
exists which calls for physical exploration. 

I have examined but one case which I am positive was incipi- 
ent or non-ulcerated cancer. In that the diagnosis was made by 
the peculiarly hard, nodular feel of the cervix, and by the coinci- 
dent implication of the vagina. Without vaginal implication I 
should have hesitated in arriving at a positive diagnosis, and I 
feel sure that he who ventures upon a decision as to the nature of 
the disease at this period must expose himself to great risk of 
error. The mere fact of the cervix being excessively hard and 
nodular is not enough to warrant a diagnosis. This must be 
accompanied by other reliable signs, as menorrhagia, hydrorrhcea, 
and constitutional failure, to make even a hypothetical conclusion 
admissible. After ulceration has occurred, diagnosis is as simple 



DIFFERENTIATION". 



431 



and certain as it is obscure and uncertain before. The ringer 
discovers an absolute destruction of tissue, and finds the walls of 

Fig. 176. 




Cancer in ulcerative stage. (Boivin and Duges.) 

the deep and ragged ulcer producing it, covered over with a 
crumbling, brittle mass, interference with which causes hemor- 
rhage. The uterus is often fixed by resulting cellulitis, and the 
walls of the vagina near the uterine junction participate in the 
deposit. Sometimes there is a stricture of the rectum, which espe- 
cially engages the attention of the patient, who suspects no dis- 
ease of the uterus or vagina. 

It is difficult to describe to another the peculiar sensation 
yielded by an ulcerating cancer, but it is easy to appreciate it by 
touch. He who carefully explores one case and marks the hard, 
unyielding border and brittle investment, with its marked tend- 
ency to crumble and produce hemorrhage, will rarely foil to 
recognize another. 

Differentiation. — Ulcerating cancer of the cervix is by no means 
difficult of diagnosis, and we are rarely called upon to decide as 
to the non- ulcerative form. 



432 



CANCER OF THE UTERUS, 



mistaken for cancer 



The diagnosis of cancer of the body is not so simple, and I 
have known many errors of diagnosis made with refereDce to it. 
As examples, I have seen in practice the following errors com- 
mitted : — 

A sloughing fibroid 

A placenta three months retained 

A sponge left by accident in utero 

Syphilitic disease of pelvic bones 

Peri-uterine cellulitis 

Syphilitic vegetations and stricture 

Cystic degeneration of chorion (hydatids) 

In such cases differentiation is attainable by one and only 
one resource — dilatation by tents, careful exploration by the fin- 
ger, and examination of the structure by the microscope. 

Prognosis. — The prognosis is pre-eminently unfavorable. Not 
only is it so from the fact that the disorder is cancerous, but be- 
cause it beloDgs generally to the most rapid and dangerous of its 
varieties. " Medullary carcinoma," says Rokitansky, "is, both in 
its development and in its subsequent course, the most acute of 
all cancers," 

Fig. 177. 



if 




Cancer in extreme degree of ulceration. (Boivin and Duges.) 

Course and Duration. — In some cases death will ensue in from 
three to six months, while in others it may not occur for five, six, 



TREATMENT. 433 

or seven years. I have under my care at present, a working woman 
who has had the disease for four years. The average duration of 
life after the commencement of ulceration is, according to Sir 
James Simpson, from two and a half to three years. The ter- 
mination is always the same — death, which may occur from sheer 
exhaustion, from hemorrhage, from irritative fever, assuming a 
typhoid type, or from some of the numerous complications which 
may develop themselves. 

Complications. — The following are the complications which most 
frequently accompany the disease : — 

Septicaemia from absorption of putrid fluid ; 

Cellulitis; 

Peritonitis ; 

Phlebitis ; 

Cancer in lymphatic glands or other organs. 
Treatment. — The indications of treatment are these : — 

To amputate or destroy the diseased part ; 

To check hemorrhage; 

To relieve pain ; 

To correct fetor ; 

To sustain the general strength. 
Ablation, which in cancroid disease is often indicated, is here 
only a forlorn hope. Indeed it will but rarely happen that 
in true cancer it will be practicable to accomplish complete re- 
moval, from its rapid tendency to involve adjacent parts. And, 
lastly, experience proves that these operations are attended by 
grave dangers, and can at best prove only palliative. 

Hemorrhage may be checked by rest during menstruation, cold 
vaginal injections, and the, use of styptics, by injection and by 
application to the bleeding surface upon pledgets of cotton. 
Should the patient employ the syringe, the most appropriate 
styptics will be the sulphate of alum, infusions of tannin or oak 
bark, or a solution of the persulphate of iron, one or two drachms 
to the pint of water. Should the practitioner make the applica- 
tion himself, a bit of cotton saturated with pure solution of the 
persulphate of iron, or a little muslin bag filled with tannin or 
powdered alum, may be placed against the os. In doing this the 
use of the speculum should be avoided if possible, for its intro- 
duction always tends to excite hemorrhage. In checking a flow 
28 



434 CANCER OF THE UTERUS. 

due to this disease, the tampon should be resorted to only in case 
of absolute necessity, for its introduction often does great injury, 
and its removal would almost inevitably excite the flow which 
had been temporarily checked. 

All these are minor means, and fall far short of the careful use 
of caustics which produce only a superficial slough and for a 
time seal up the mouths of the bleeding vessels. Once in every 
two or three weeks the surface of the diseased mass may be lightly 
touched, after being cleansed by syringing with cold water, by 
the actual cautery, acid nitrate of mercury, or chemically pure 
nitric acid. Care must be taken not to create a deep slough, 
lest this being cast off the peritoneal cavity may be opened into. 

The relief of pain should be accomplished by the free, unre- 
stricted use of opium by the mouth, the rectum, the vagina, or 
under the skin. I often encourage my patients to become opium 
eaters, and urge them to obtain as complete relief as the use of 
this drug can afford. In place of opium other narcotics may be 
tried, but there is none which compares with it for efficiency. 

When opium produces the painful results noticed where an 
idiosyncrasy exists against it, the persistent use of it will often 
effect a tolerance. 

The fetor of the discharges may be, to a great extent, corrected 
by the use of vaginal injections containing disinfectant substances 
in solution. Solution of carbolic acid from one to two drachms 
to a pint of water, Labarraque's solution of soda in the same pro- 
portion, one drachm of powdered persulphate of iron to the pint, 
or a weak solution of the iodide of lead, will prove very useful. 
Of all these, carbolic acid is the most certain and effectual. 

The general strength should meantime be maintained by fresh 
air, residence in the country, generous food, alcoholic stimulants, 
iron, and bitter tonics, while the mind should be kept cheerful by 
lively company, and avoidance of the society of those who 
encourage conversation concerning the existing disease. As the 
digestion is weak, the most digestible substances should consti- 
tute the staple diet, and very often a patient who will become ema- 
ciated upon solid food and a mixed diet will improve upon the 
exclusive use of milk, beef-tea, and similar substances. So 
marked is this fact, that the milk diet strictly adhered to has been 
'regarded, and is now, by many non-professional persons, as a 
means of cure for cancer. 



CHAPTER XXXII. 

CANCROID TUMORS OF THE UTERUS. 

Between cancer on the one hand and fibrous tumors on the 
other, there is a doubtful, debatable ground which is occupied by 
what are called cancroids or cancroid tumors. 

This term which is derived from " cancer" and " ft5o?," implies 
a great similarity between this disease and true cancer, and yet 
they are far from being identical. Both have an interstitial 
origin, both affect the surrounding tissues, and both, if removed, 
are \ery prone to return. But they present these differences : 
cancer is less curable, presents a characteristic cell, and is much 
more likely to poison surrounding parts. Cancroid does not pre- 
sent cells of such abnormal type, and upon section shows no can- 
cerous juice. 

Varieties. — The varieties of uterine growths coming under this 
category are the fibro-plastic and recurrent fibroid. Of the latter 
there are several species, as the myeloid, fibro-nucleated, &c. 

Fibro-plastic Tumors. 

To this class belong many tumors which in their commence- 
ment are curable, but in their progress develop the features of 
malignancy, for example, malignant polypus. 

Pathology. — Although having, like cancer, an interstitial origin, 
they differ from it both clinically and anatomically. The charac- 
teristic cell is smaller and has a smaller nucleus. The cells of 
this morbid growth are larger, however, than those of any other 
lymph-tumor, excepting cancer. They are of an oval form, with one 
elongated extremity, and flask-shaped, as Mr. Paget has expressed 
it. Mr. Collis declares that as soon as the full distension of the 
tumor is reached, its covering, whether of skin or mucous mem- 
brane, gives way, and an ulcer is formed, from which a fungus 



436 CANCROID TUMORS OF THE UTERUS. 

protrudes, which by hemorrhage and discharge exhausts the 
patient's strength. 

Clinically this difference is noticed between it and cancer. 
While the latter is developed as a result of a vitiated blood state, 
the first exists for some time without affecting the system, and 
may before such a result has occurred be removed without return. 
But its tendency to return is marked, and the secondary growths 
are always more malignant than the primary. 

Upon section, fibro-plastic tumors leave a clear white surface, 
uncovered by fluid, and quite hard to the touch. 

Recurrent Fibroid Tumors. 

Definition. — This term has been applied by Mr. Paget to a 
tumor in many respects resembling fibrous tumors, and yet en- 
dowed with the unfortunate feature of recurrence after removal, 
and tendency to ulceration and fungous degeneration. 

Pathology. — " These growths," says Mr. Collis, " are of a firm, 
elastic feel, a more or less globular outline, and lobed sometimes 
by the pressure of an intersecting fascia or band. They are 
unattended by any special pain, and free from glandular or con- 
stitutional complication." Like the fibro-plastic tumor they ulti- 
mately ulcerate, and free flow of blood occurs. Then a fungous 
growth protrudes, which, by hemorrhage and discharge, exhausts 
the patient. Under the microscope the elements of this form of 
tumor appear to be elongated, caudate cells, interspersed with free 
nuclei and young cells. 

For most of the facts connected with this subject, as for the 
classification adopted, I am indebted to the work of Mr. M. H. 
Collis, of Dublin, upon Cancer and Tumors, to which I refer the 
reader. 

For the pathologist there is much to study in the various 
forms of uterine tumors belonging to this class. For the Gyne- 
cologist there is less, for the following are the only facts con- 
nected with the subject which are of clinical importance: — 

1st. That there is a class of tumors resembling fibroids, yet 
presenting a tendency to ulcerate, develop fungus, and persistently 
refuse to heal ; 

2d. That this class, if removed, is almost as prone to return as 
cancer itself; 



FKEQUENCY. 437 

3d. That if removed in its incipiency, the system may possibly 
be left unirnplicated, while, if allowed to remain in situ for a 
longer time, it will become involved. 

Prognosis. — The prognosis of both forms is unfavorable, al- 
though there is a possibility that no return may take place after 
removal, if this be practicable. 

Frequency. — Fortunately they very rarely develop themselves 
in the uterus. Lebert declares that they may do so, and Dr. West 1 
mentions several cases. I have myself met with but one case 
concerning which I felt positive, and even in this the conclusion 
was supported by clinical evidence alone. This patient I saw in 
consultation with Prof. Budd. The tumor, hard and elastic, was 
attached to the inner wall of the cervix, and extended upwards to- 
wards the cavity. It presented to the touch a hard, carcinomat- 
ous resistance, not unlike that of a fibroid, and, although not 
larger than a wain at, had undermined the patient's strength com- 
pletely. It was in time attacked by ulceration, from which pro- 
fuse hemorrhage occurred, and destroyed life. 

i Op. cit. 



CHAPTEE XXXIII. 

EPITHELIOMA, OK EPITHELIAL CANCER OF THE UTERUS. 

Cancer of the uterus, as of all other parts of the body, has 
two distinct stages, that of deposit and that of destructive ulcera- 
tion. In the first of these a deposition of the materies morbi 
takes place in the interstitial portions of the structure affected, 
and as the second period becomes established this forms a connec- 
tion with the surface by ulceration. In certain cases the morbid 
influence, instead of exciting interstitial deposit, is exerted upon 
the mucous membrane itself, affecting its production of epithelial 
cells. In such cases no deposit occurs in the tissue underlying 
the mucous membrane. To this class the names of epithelial 
cancer, epithelioma, carcinomatous ulcer, and cauliflower excre- 
scence, have been applied. As Mr. M. H. Collis 1 remarks, its 
special name is unimportant, " if its difference from cancer and its 
analogies to it be kept clearly in view." 

Although in many respects kindred to cancer, it differs from it 
so essentially in others as to call for a separate consideration of 
the two. The most marked differences existing between cancer 
and epithelial cancer are these : — 

Cancer 



Is deposited in the parenchyma ; 
Invariably returns if removed ; 
Is from the first a constitutional disease 
Soon affects neighboring parts ; 
Runs usually a very rapid course ; 
Is characterized by a peculiar cell. 



Epithelial Cancer 
Begins with no interstitial deposit 
Does not return as a rule ; 
Is at first a local evil ; 
Slowly affects neighboring parts ; 
Progresses slowly ; 
Has no characteristic cell. 



Varieties. — Epithelial cancer may affect the uterus in two 
forms : — 

Corroding ulcer; 
Cauliflower excrescence. 
Each of these will in turn engage our attention. 

1 On Cancers and Tumors. 



EPITHELIOMA. 439 

Ulcerating Epithelioma, or Corroding Ulcer of the Uterus. 

Definition. — The term corroding ulcer was applied by Dr. John 
Clarke, of London, and subsequently by his brother Sir Charles 
Mansfield Clarke, to a form of ulcer of the cervix in which nothing 
but rapid destruction of tissue is noticed as a pathological lesion; 
in which there is no hardness of the part affected; no induration 
or inflammation of surrounding organs, nothing but molecular 
death in the cervix uteri, and disappearance of its structure as if 
by liquefaction. 

Synonymes. — It has been described under the names of phage- 
denic ulcer, diffuse ulcerative cancer, epithelial cancer, and can- 
croid of the uterus. 

Frequency. — All authorities agree that this affection is compara- 
tively rare. Dr. Ashwell 1 remarks : "For one case of corroding 
ulcer we meet with ninety or a hundred of cancer of the uterus ;" 
and he further states that in the appropriate ward at Gruy' s Hospital 
at the time of his writing, not one example of the malady had 
appeared. In five hundred recorded cases of uterine disease in 
that hospital not one case of corroding ulcer was to be found. 
This is the experience of all authors who make their reports, not 
from clinical, but from careful post-mortem evidence. Those 
who rely upon clinical observation alone report the disease much 
more frequently ; but it is highly probable that, as Scanzoni 2 re- 
marks, an error has been made in such cases with reference to 
their anatomical characteristics. It should be borne in mind that 
many cases proved by the microscope in post-mortem inspection to 
be unquestionably cancerous, have run a course very similar to 
the epithelial form of the affection. Ashwell states that on seve- 
ral occasions where a diagnosis of corroding ulcer had been made, 
post-mortem examination gave evidence of true cancer ; and Scan- 
zoni tells of a case occurring in the clinique, at Prague, in which 
at an autopsy all present were inclined to reverse their diagnosis 
of cancer and adopt that of corroding ulcer, until the matter was 
settled by discovery of cancerous elements. It is only in view of 
these facts that I can account for the frequent reports of this dis- 
ease made in public societies and private conversations in this city- 

1 Dis. of Women, p. 318. 2 Op. oit., p. 226. 



440 



EPITHELIAL CANCEK OF THE UTERUS, 



I "have myself met with two cases presenting clinically all the cha- 
racteristic signs of corroding nicer, but in neither was antopsic evi- 
dence obtained. Two very interesting cases are reported by Dr. 
Gardner, 1 in the American edition of Scanzoni, in one of which 
merely the peritoneal shell of the uterus existed at the time of 
death ; yet both are invalidated for science by want of microsco- 
pical investigation. 

Pathology. — Pathologists are now very generally agreed that 
this affection is a variety of epithelial cancer, as the following 
table will prove. In preparing it no author is quoted who wrote 
over twenty-five years ago. 

Opinion as to Pathology. 



Authority. 
Dr. West 

Dr. Graily Hewitt . 

Dr. Churchill 

M. Aran 

Dr. Scanzoni 

M. Nonat 

M. Becquerel 

Dr. Ashwell . 

Dr. H. Bennet 
Dr. Tilt 

Dr. Byford . 

Dr. Lever 

Dr. Kiwisch . 

M. Colombat de 

L'Isere 
M. Courty 



Epithelial cancer 

Quotes and appears to in- 
dorse West 

" Essentially different" from 
cancer 

Diffuse ulcerating cancer . 

Decomposed medullary can- 
cer. 
Epithelial cancer 

Epithelial cancer 

Similar to lupus . 

Epithelial cancer 
No allusion to it . 

Epithelial cancer 

Malignant ulcer . 

Decomposed medullary can- 
cer. 

Compares it to noli me tan- 
gere. 
I Epithelial cancer 



Where reported. 

West on Diseases of Females, 
p. 270. 

Hewitt on Diseases of Wo- 
men, p. 259. 

Churchill on Diseases of Wo- 
men, p. 208. 

Aran, Mai. de l'Uterus, p. 
937. 

Scanzoni on Diseases of Fe- 
males, p. 227. 

Nonat, Mai. de l'Uterus, p. 
521. 

Becquerel, Mai. de l'Uterus, 
torn. ii. p. 209. 

Ashwell on Diseases of Fe- 
males, p. 319. 

Bennet on Uterus, p. 386. 

Uterine and Ovarian Inflam- 
mation. 

Byford, Med. and Surg. Treat, 
of Women. 

Lever on the Diseases of the 
Uterus, p. 149. 

Scanzoni, Dis. of Females, p. 
227. 

On Females. 

Mai. de l'Uterus, p. 875. 



Kokitansky 2 says : " We also find primary and syphilitic ulcers, 
cancerous ulcers that have resulted from the fusion of cancerous 



1 Op cit., p. 223. 



Path. Auat. Sydenham ed., vol. ii. p. 220. 



PHYSICAL SIGNS. 441 

morbid growths, the so-called phagedenic ulcer of the os tincae, 
Clarke's corroding ulcer. The latter may be compared to the 
phagedenic, cancerous sore of the skin ; without having a morbid 
growth for its base it gradually destroys the cervix and even the 
greater part of the uterus, and may extend to the rectum and 
bladder.'' 

Mode of Development. — On this point nothing is known. The 
infrequency of the disease and the fact that the physician is called 
after it has progressed for some time, will explain our ignorance. 
No better proof of the uncertainty attaching to this point can be 
given than the fact that Kiwisch and Scanzoni 1 both regard the 
ulcer as the base of a decomposed encephaloid cancer. 

Course, Termination, and Prognosis. — Like cancer the inevitable 
tendency of this affection is to death. As the process of destruc- 
tion advances through the mucous membrane into the parenchyma 
beneath it, and profuse hemorrhages occur, the patient is gradu- 
ally exhausted, and as the peritoneum in time becomes invaded, 
peritonitis of fatal type is excited. Unlike cancer, however, its 
course is often slow, and years may pass before death results. 
Upon these facts, and the additional one that the disease is in its 
commencement a local affection, a prognosis of very grave charac- 
ter, though somewhat less grave than that of cancer, may be con- 
fidently based. 

Symptoms. — The symptoms which mark its development are 
very similar to those of cancer, from which it can never be diag- 
nosticated except by physical means. The most prominent are — 

Hemorrhage ; 

Fetid, ichorous, and watery discharge ; 

Pain in back and pelvis ; 

Emaciation; 

Slight fever. 
The character of the pain is much insisted upon by Sir Charles 
Clarke as diagnostic. He declares that it is hot and burning, but 
not lancinating. Little reliance can be placed upon this sign, and 
to arrive at a diagnosis, physical examination is always necessary. 
Physical Signs. — Upon vaginal touch an ulcer, whose base is 
covered by minute and unequal projections, is found to have eaten 
away the cervix to a greater or less extent. Besides this nothing is 

1 Op. cit., p. 227. Am. ed. 



442 



EPITHELIAL CANCER OF THE UTERUS, 



discovered. The uterus is movable, no hardness is found above 
the ulcer, and no glandular or other induration exists in the pelvis. 
A corroding or gnawing ulcer, " ulcere rongeant," is found to 
have devoured a part or the whole of the cervix, and beyond this 
nothing is ascertainable. 

Differentiation. — It may be confounded with granular ulcer, 
syphilitic ulcer, and ulcerated cancer. From the first two it may 
be known by its fetid and ichorous discharges, profuse hemor- 
rhages, extensive destruction, and the peculiarly gritty feel of 
its surface. The differentiation from cancer is so difficult, and at 
the same time important, as to call for a comparison of symptoms. 



In Cancer, 

There is deposit in the uterus and other 

pelvic organs ; 
Uterus is somewhat immovable ; 
Vagina generally affected ; 
Other organs often affected ; 
Constitution profoundly involved ; 
Bladder and rectum often opened into. 



In Corroding Ulcer, 

There is no deposit in the uterus or 

other organs ; 
Uterus is movable ; 
Vagina free from disease ; 
No other organs affected ; 
Not so profoundly affected ; 
Rarely so. 



Causes. — On this subject nothing is known. 

Treatment. — Should the disease be detected early, and sufficient 
grounds be discovered for the maintenance of a positive diagnosis, 
the propriety of complete removal of the cervix by amputation 
cannot be questioned. If the disease be cancer, and not epithe- 
lioma, the operative procedure will fail in effecting a cure, but 
will probably not hasten a fatal issue. If it be the latter, a cure 
may be accomplished. 

If it be thought best not to resort to amputation, cauterization, 
by means of the actual cautery, acid nitrate of mercury, or potassa 
cum calce, should be made to destroy the diseased surface as deeply 
as proves compatible with safety, in the hope that as the slough 
separates a healthy, granulating base may replace the old and 
vicious one. Dr. Churchill thus speaks of the use of strong nitric 
acid as a caustic: " 1 have found it relieve pain, arrest hemorrhage, 
and restrain the discharges. In one case, hopeless when I first 
saw her, life was prolonged for three years under this treatment." 
If by these means the rapid progress of the disease may be 
checked, as we have every reason to believe that it may, it is 
incumbent upon the practitioner to essay them even when not 
absolutely positive of the correctness of his diagnosis, for besides 






FREQUENCY. 443 

them we have no others that ever prove curative. Should they 
fail, all that remains for us to do is to palliate the evils arising 
from the disease. 

The vagina should be kept clean, and irritation within it re- 
lieved by frequent syringing with tepid water containing in admix- 
ture carbolic acid, Labarraque's solution, glycerine, or some other 
disinfectant. The violence of the hemorrhage should be controlled 
by pledgets of cotton saturated with solution of the persulphate 
of iron and laid against the bleeding surface, and pain should be 
relieved by vaginal or rectal suppositories of opium or belladonna. 
At the same time that these local means are being resorted to, the 
general state of the patient should be improved by fresh air, care- 
fully regulated exercise, nutritious food, tonics, and chalybeates. 

Vegetating Epithelioma, or Cauliflower Excrescence of the Uterus. 

Definition and Synonymes. — This peculiar affection, which has 
been described under the names here employed and under that of 
cauliflower tumor of the uterus, consists in an hypertrophy of the 
villi of the cervix with great increase of their vascularity. The 
term cauliflower excrescence was applied to it in 1809, by Dr. 
John Clarke, from its resemblance to the vegetable known by 
that name, and is so graphic that it has been retained by all Eng- 
lish writers since that time. 

Frequency. — -Epithelial cancer, of the vegetating, as of the ulce- 
rating form, is rare. Dr. "West, in 120 cases, met with it only ten 
times, while encephaloid cancer existed one hundred and eight 
times. Becquerel 1 goes so far as to treat the question of frequency 
in these words : "If this malady really exists, no one will deny 
that it is very rare, or I have been little favored by chance, for I 
have studied uterine diseases for ten years and have never met 
with a single case." During a practice of fifteen years I have 
met with eight cases. One, of large size, was' seen with me, 
and the diagnosis corroborated, by Prof. W. H. Yan Buren, and 
two others, which presented themselves at my College Clinique, 
by Dr. J. L. Brown. The first ended fatally from hemorrhage, 
and of the second two I unfortunately lost sight. The five 
remaining cases all ended fatally, developing the ordinary symp- 
toms of cancer. 

1 Mai. de PUterus, torn, ii., p. 214. 



444 EPITHELIAL CANCER OF THE UTERUS. 

Anatomy. — Before studying the pathology of this disease, it is 
necessary to have definite ideas concerning the normal anatomy 
of the mucous membrane of the vaginal extremity of the cervix, 
which is its usual seat. The researches of Dr. Franz Kilian, of 
Bonn, and of Drs. Tyler Smith, Hassall, and Jones, of London, 
have proved that this part is covered over by papillas, which 
stand forth like a fringe. Each villus is covered by pavement- 
epithelium, and contains within itself a looped vessel which 
passes to its extremity, then returns and inosculates with the 
bloodvessels of neighboring villi. Sometimes two or three vas- 
cular loops will be found in the same villus, if of large size. Each 
villus thus projecting from the mucous membrane is covered over 
its whole surface by pavement-epithelium. 

Pathology. — The disease which we are considering consists in 
an extraordinary development of these villi, an increase of their 
vessels, and a great activity in the growth of the cells which cover 
them, a " proliferation," as it is termed by Virchow. A morbid 
influence, the nature of which is unknown to us, stimulates the 
activity of cell growth so that cells thickly cover the villi. 
" These growths," says Prof. J. H. Bennet, " speaking generally, 
are almost wholly composed of epithelial scales." In addition, the 
villi increase in size and length, their bloodvessels enlarge, and a 
true papilloma or papillary tumor is inaugurated. " The gall-nut 
which arises in consequence of the puncture of an insect, the tube- 
rous swellings which mark the spots on a tree when a bough has 
been cut off, and the wall-like elevation which forms around the 
border of the wounded surface, produced by cutting down a tree, 
and which ultimately covers in the surface, all of them depend 
upon a proliferation of cells just as abundant, and often just as 
rapid as that which we perceive in a tumor of a proliferating part 
of the human body." 1 Fig. 178 represents one of these growths in 
section. 

It must not be supposed that these masses are supplied by blood 
only by the vessels of the villi. These ramify outside of their 
proper canals and running into the mass of cells allow of transu- 
dation of serum which constitutes the watery discharge so cha- 
racteristic of the disease, and being ruptured give forth a profuse 
flow of blood. 

1 Virchow, Cellular Pathology. 



PATHOLOGY, 
Fig. 178. 



445 




Transverse section of a vegetating epithelioma. (Virchow.) 

These tumors, commencing as papillary hypertrophies on the 
cervix or os, are at first local, but in time affect the constitution. 
They are sometimes engrafted upon true cancerous deposit in the 
cervical parenchyma. • 

Their most frequent site is the vaginal portion of the cervix, 
but from this point the morbid process may spread into the 
uterine cavity or down into the vagina. An important, indeed a 
vital, question as to such growths is this : Is every cauliflower 
excrescence a malignant disease ? Yirchow, than whom we 
know of no better authority, is decidedly of opinion that it is not. 
" The pathological importance of a papillary tumor," says he, " is, 
at least as far as I know, determined by the condition of its basis 
substance, or by that of the parenchyma of the villi themselves; 
and a formation can only be pronounced to be cancroid or carci- 
noma when, in addition to the growth of the surface, the peculiar 
degenerations which characterize these two kinds of tumors take 
place also in the deeper layers or in the villi themselves." 

Virchow then believes that some tumors, resembling in every 
outward aspect cauliflower excrescence, are really non-malignant 



446 ' EPITHELIAL CANCER OF THE UTERUS. 

papillomata. The difference between these and the real epithe- 
lioma is to be found by microscopic examination of the submucous 
tissue. In the one case it is healthy, in the other diseased. 

This opinion, arrived at by the learned German pathologist by 
careful microscopic research, was maintained as a result of clinical 
observation many years ago by Dr. Gooch, who said : " I do not 
believe that any man can tell infallibly by touch whether a tumor 
in the vagina is a malignant excrescence, which is to grow again, 
or a benign one, which, if removed, will never return." 

The pathological condition that we have thus far described 
may be styled the first stage of the disease. In time ulceration 
occurs in the mass thus created, which, rapidly breaking down its 
tissue, opens large and numerous vessels, and destroys life by 
long-continued and profuse hemorrhages. 

Causes. — The same dearth of precise knowledge which attends 
the etiology of malignant disease of other forms attaches to this. 
Symptoms. — The chief symptoms are these : — 

Discharge of bloody water like the washings of beef; 
Hemorrhage ; 
Profound spanasmia ; 
CEdematous swellings ; 
Gastric disorder, vomiting, and dyspepsia ; 
In time, fetid discharge. 
The discharge of water is sometimes so profuse as to saturate 
a large number of towels during each day. 

Fig. 179. 




Vegetating epithelioma. (Simpson.) 



DIFFERENTIATION — PROGNOSIS. 447 

Hemorrhage sometimes follows slight injuries, as coition, &c, 
in the beginning, but soon occurs spontaneously and profusely. 

The other symptoms enumerated are not properly symptoms of 
the disease, but of one of its results, hemorrhage. 

Physical Signs. — These are of the utmost importance for diag- 
nosis, for without them no decision can be reached. 

Yaginal touch reveals a nodulated tumor which is generally 
attached to one lip of the os. This is not smooth and even, like 
a fibroid growth, but soft and uneven like the uterine surface of 
the placenta. Upon slight tactile interference it will bleed freely 
and show a marked tendency to crumble under firm pressure. 

Differentiation. — It may be confounded with — 
Syphilitic vegetations ; 
Eetained placenta; 
Simple papilloma ; 
Cancer ; 

Syphilitic vegetations will be known by their dependence upon 
a constitutional vice which demonstrates itself by other signs, and 
by their readily yielding to specific treatment. 

A retained placenta may mislead the practitioner, but a differ- 
entiation will readily be accomplished by microscopic examination 
of a portion of the mass and by dilatation of the cervix by sponge 
tents. 

Simple Papilloma. The authority of Virchow has been al- 
ready quoted to prove how difficult is a differentiation from this 
disease in its commencement. Indeed, Scanzoni 1 declares that 
Yirchow is of opinion that " the excrescence is at first a simple 
papillary tumor, which afterwards passes into a cancroid state." 

Cancer in any of its varieties may be recognized by induration 
of the tissue above the nodulated, exuberant mass which projects 
into the vagina, and also by the smaller amount of the profuse, 
watery discharge. 

Prognosis. — If the disease be discovered early enough for com- 
plete removal to be practised, the prognosis is good, but otherwise 
it is eminently unfavorable. 

Treatment. — Should amputation of the neck promise entire 

' Op. cit.,p. 291. 



448 EPITHELIAL CANCER OF THE UTERUS. 

removal of the morbid tissue, it should at once be practised by 
the ecraseur, the curved scissors, or the galvano-caustic. 

If this be impracticable from any cause, the growth should be 
destroyed as completely as possible by the actual cautery, potassa 
cum calce, one of the mineral acids, or the gas jet cautery. The 
last is applied by means of a metal tube attached to one of gutta- 
percha, which connects with a reservoir of the ordinary gas used 
for lighting buildings. Through the end of the metallic tube a 
minute jet escapes, which being lighted, is brought in contact 
with the morbid growth through a speculum. It soon destroys 
the surface entirely, and possesses certain advantages not attach- 
ing to other methods, but it is infinitely less manageable than the 
white hot iron. 

Should it have involved so much of the uterus that complete 
removal is impossible, the physician will be forced to limit his 
interference to the fulfilment of these three indications : 
Controlling hemorrhage ; 
Correcting fetor ; 
Sustaining the general strength. 

The first may be to a limited extent accomplished by the appli- 
cation of pledgets of cotton or the use of vaginal injections medi- 
cated with the persulphate of iron, alum, or tannin. 

The second may be fulfilled by injections into the vagina of 
water medicated by carbolic acid, Labarraque's solution, the sul- 
phate of iron, or other disinfectants. 

The third indication will require tonics, good diet, fresh air, 
and stimulants. 



CHAPTEE XXXIY. 

DISEASES RESULTING FROM PREGNANCY. 

In the non-pregnant state, the parenchyma of the uterus consists 
of fibrous tissue, resembling that of fibrous tumors, with fibre 
cells disseminated throughout it; and the cavity of the organ is 
lined by a mucous membrane so indistinct that within the present 
century its very existence has been contested. No sooner does 
" fixation of the impregnated ovum," 1 or conception occur, than 
the fibre cells begin to elongate themselves into powerful muscular 
fibres, the mucous membrane actively generates cells, and the ute- 
rus rapidly enlarges to meet the wants of its increasing contents. 
When the period of pregnancy is terminated by labor, and 
diminution of the enlarged uterus proceeds in accordance with 
given laws, the organ chiefly concerned in the process is left in a 
state of perfect health. But a variety of accidents may occur 
which will entail disease upon it. The foetus may be expelled or 
become atrophied, and the membranes continue to grow ; even a 
small portion of retained chorion may undergo cystic or hydatidi- 
form degeneration; or the child being born at full term, the uterus 
may not return to its original size, or may diminish too much and 
become atrophied. 

The diseases resulting from such abnormal conditions are — 

Moles ; 

Hydatids ; 

Subinvolution ; 

Superin volution. 

UTERINE MOLES. 

Definition. — By this term is meant the existence in the cavity 
of the uterus of a fleshy mass which cannot be classed among 
tumors or polypi. 

» Prof. C. D. Meigs. 

29 



450 DISEASES RESULTING FROM PREGNANCY. 

The appellation of mole is neither elegant nor appropriate, but 
it is sanctioned by use for so great a length of time that it is diffi- 
cult to alter or discard it. 

History. — Ancient medical literature teems with theories, hy- 
potheses, I might almost say fables, upon this subject. It would 
be unprofitable even to enumerate the extravagant and baseless 
surmises indulged in upon it, but as an example I will mention 
that Aristotle, 1 Hippocrates, Galen, and the Latin authors regarded 
moles as due to want of virtue in the seminal fluid, or to a super- 
abundance of menstrual blood. 

A certain superstition has attached to them even in modern times ; 
thus Capuron quotes Mahon for the following very curious asser- 
tion. " The housewives believe that moles not only take the 
forms of certain animals, but that they even walk, run, fly, try to 
hide themselves, even to re-enter the womb from which they came ; 
indeed, if no obstacle be offered, they will kill the woman just 
delivered of them." Levret pointed out the fact that they are 
only the retained foetal shell, which, by the establishment of a low 
grade of nutrition, continues to exist. 

Pathology. — As the foetus passes into the uterus it is enveloped 
by its proper membranes, the amnion and chorion, and these are 
surrounded by a prolongation of the hypertrophied mucous lining 
of the organ, called the decidua reflexa. Between the end of the 
second and the end of the third month the placenta is formed and 
the villi of the chorion not engaged in its development become 
atrophied. Before that time the foetal shell is quite thick, and is 
everywhere in close communication with the uterine walls. 

Many adverse influences may destroy the life of the foetus, and 
generally, as a result, the whole of the products of conception are 
swept away by uterine contraction. But sometimes the shell of 
membranes clings to its attachment, and for an unlimited period 
holds its position in utero. 

Causes. — There are many intra-uterine growths and collections 
which, being cast off, may be mistaken for moles, as, for example, 
masses of coagulated blood, polypi, decidual membranes, &c, but 
it is very doubtful whether a true mole ever exists except as a 
result of conception. Why the foetal investments should be cast 

1 Capuron, Mai. des Fernmes, p. 268. 



UTERINE MOLES. 451 

off in some cases, while in others they remain and undergo de- 
generation, it is impossible to say. 

Symptoms. — The condition generally announces itself by these 
symptoms : — 

Menorrhagia or metrorrhagia ; 
Hypogastric weight and uneasiness ; 
Uterine tenesmus ; 
Slight constitutional disturbance ; 
Cessation of signs of pregnancy. 
Physical Signs. — Vaginal touch will reveal the fact that the 
uterus is enlarged, and the uterine probe may assure us that its 
cavity contains some solid substance, but neither these nor any 
other means at our command will enlighten us as to its character. 
Hence the diagnosis of uterine moles is very obscure and always 
uncertain. "When a patient who has exhibited all the signs of 
pregnancy suddenly ceases to do so and presents those just enume- 
rated, it may be suspected. A more accurate diagnosis than this 
can rarely be attained. The condition being suspected, the cervix 
should be dilated by tents, and uterine action excited by ergot 
in order to settle the question. 

Differentiation. — This disease may be confounded with — 
Fibrous tumor; 
Cancer of the body ; 
Subinvolution. 
From all, the differentiation may be accomplished in one way 
and one way only, dilatation of the cervix by tents, and careful 
exploration of the cavity of the uterus. 

A fibrous tumor is hard, smooth, and resisting, while a mole is 
soft, spongy, and yielding to the touch. 

Cancer will be known by its peculiar feel, its fetid discharges, 
and the constitutional implication attending it. 

Subinvolution yields to exploration the fact that the uterus is 
empty. It also follows delivery while the mole rarely does so. 
Prognosis. — The prognosis is favorable.. 

Treatment. — The cervical. canal should be fully dilated by tents,' 
and an effort made to arouse uterine contraction by persistent use 
of ergot. Should this fail, the mass should be cautiously re- 
moved by the curette, or by traction by means of the placental 
forceps. 



452 



DISEASES RESULTING FROM PREGNANCY. 



CYSTIC DEGENERATION OF THE CHORION OR UTERINE HYDATIDS. 

Definition. — The chorion remaining attached to the uterine Avails 
after expulsion or death of the embryo, sometimes undergoes 
a peculiar metamorphosis which receives this appellation. True 
hydatids, that is, cysts due to the presence of the acephalocyst, 
are very rarely met with in the uterus. Their extreme rarity 
may be judged of from the fact that Kokitansky declares that he 
has never discovered them but once. Dr. Graily Hewitt 1 
believes that when they exist in the uterine cavity, it is probable 
that they are discharged into the peritoneum from rupture of a 
cyst in the liver, and thence pass through the uterine wall. Not 

Fig. ]80. 




Cystic degeneration of chorion. (Boivin and Duges.) 

only do the grape-like cysts making up what is commonly known 
as uterine hydatids, differ from true hydatids in absence of the 



1 Op. cit., p. 75. 



UTERINE HYDATIDS. 453 

acephalocyst, they are also unlike in their appearance and forma- 
tion. The former are developments of little sacs in a series, as 
if strung together ; the latter are closed sacs, one within another. 

Synonymes. — The affection has been described under the names 
already given, and under those of vesicular mole in contra-dis- 
tinction to fleshy mole just investigated, hydatidiform mole, and 
hydatid pregnancy. In most works it is described as only a 
variety of mole. 

Pathology. — It is probable that after the end of the third month, 
no such degeneration can occur in the secundines — for after that 
period the placenta is formed, the villi which existed at its site 
become vascular, and those over other parts of the surface of the 
foetal sac undergo atrophy. It is true that at the period of par- 
turition, masses of these sacs have, in rare instances, been ex- 
pelled, but in such cases it is probable that some portion of the 
chorion had begun to degenerate at an early period of concep- 
tion. 

Eemaining in connection with the uterine walls, and absorbing 
nourishment which is no longer appropriated by the growing 
foetus, the villi undergo a kind of dropsical swelling, which 
results in the grape-like bodies styled hydatids. 

Causes. — We know of no influences which excite this form of 
degeneration in a retained chorion. 

Symptoms. — Sometimes the disease demonstrates its presence 
by all the signs of pregnancy, abdominal enlargement being one 
of the most prominent. Suspicion as to the existence of some- 
thing abnormal is very generally excited at an early period by 
some or all of the following signs : — 

Discharge of clear or bloody water ; 
Hemorrhage ; 
Uterine tenesmus ; 
Constitutional disturbance ; 
Discharge of little cysts. 

Physical Signs. — Yaginal touch will reveal the uterus enlarged, 
and the os patulous, as if the cavity of the organ were tilled with 
something, and conjoined manipulation would prove this to be 
fluid and not solid. 

If, with these signs, the fact that cysts had been discharged 
could be ascertained, the diagnosis would be complete. If it 



454 DISEASES RESULTING- FROM PREGNANCY. 

is not so, the cervix should be dilated by tents, in order that 
the cavity of the body may be explored by touch, or that a 
portion of the mass may be removed. 

Differentiation. — It might very readily be confounded with — 
Pregnancy ; 
Polypus ; 
Cancer of the body of the uterus. 

From pregnancy it could generally be distinguished by the 
very rapid development of the uterus, the presence of watery 
and bloody discharges, and the absence of quickening, ballotte- 
ment, and other signs of that state. 

From polypus a diagnosis could readily be made by tents, and 
the uterine sound. 

Cancer would be known by fetid discharge, great constitutional 
decadence, and the much smaller size of the uterus than in hy- 
datids. 

Prognosis. — If the case be one of true hydatids due to the 
acephalocyst, the prognosis would be very grave. If it proved 
to be one of cystic degeneration of the chorion, it would be 
favorable. 

Treatment. — The treatment should consist, 1st, in full dilatation 
of the cervical canal by tents and Barnes's dilators; and 2d, in the 
expulsion of the mass by ergot, or the introduction of the curette, 
a looped wire, or other appropriate instrument into the uterus. 

SUBINVOLUTION OF THE UTERUS. 

Definition. — By this term is signified the fact that the retro- 
grade metamorphosis, by which the uterus enlarged from preg- 
nancy returns to its original size, stops short of completion, and 
leaves the organ larger than it should be. 

History. — It is only within the past twenty years that we have 
understood the processes by which the uterus, an organ measur- 
ing three inches, in the short space of nine months enlarges so as 
to contain two or even three children, and then, within two months 
after delivery, undergoes so rapid an absorption as to return to its 
original size. The credit of elucidating the subject belongs 
chiefly to Germany, for it is to Yirchow, Franz Kilian, Hesch, 
Kolliker, and Eetzius that we are chiefly indebted. 

The important practical bearing of the subject was developed 



SUBINVOLUTION OF THE UTERUS. 455 

by Sir James Simpson, who in 1852 published the first article 
which drew especial attention to it. His article was entitled, 
" Morbid Deficiency and Morbid Excess in the Involution of the 
Uterus after Delivery." Since that period it has become gene- 
rally recognized as a uterine state of no great infrequency. 

Pathology. — After delivery the fully developed fibres of the 
uterus undergo a fatty degeneration; the fat thus formed is 
absorbed, and the organ rapidly diminishes. Certain untoward 
influences may retard or check this process, when the uterus 
remains flabby and large, and is said to be in a state of subinvo- 
lution. 

Causes. — The most prominent of these are the following : — 
Metritis ; 

Uterine congestion; 
Uterine atony. 

Metritis of the uterine parenchyma, whatever be its cause, 
retards and checks involution. 

Congestion is often induced after delivery by too early exertion, 
abuse of coition, and constipation. 

Uterine atony, by allowing the sinuses of the uterus to remain 
open after labor, favors a sluggish circulation, a lax fibre, and 
tends to produce the disorder which we are considering. 

Symptoms. — The disease presents the following symptoms: — 
Menorrhagia or metrorrhagia; 
Leucorrhcea of watery character ; 
Pain in the pelvis, back, and thighs. 

Prognosis. — The prognosis as regards the life and health of the 
patient is good, but that as to rapid recovery is not so favorable. 
To a certain extent it will depend upon the patient's ability to 
yield to treatment, and allow the means at our command a fair 
opportunity to exert their influence. 

Results. — Unless it be cured, subinvolution will very likely 
result in displacement and metritis, with their long list of dis- 
comforts. 

Treatment. — It should be the first care of the practitioner to 
discover the influence checking the necessary physiological pro- 
cess, and to remove this. If sensitiveness upon pressure, slight 
febrile action, and leucorrhcea, lead to the belief in the existence 
of metritis, this should be treated by leeching the cervix or peri- 



456 DISEASES RESULTING- FROM PREGNANCY. 

neum, perfect rest, fomentations, and laxatives. Should conges- 
tion be found to exist, it should be treated upon the same prin- 
ciple, at the same time that its cause should be removed. Atony 
of the uterine fibres should be removed by ergot, strychnine, the 
shower-bath, and electricity. 

SUPEKINVOLUTION OF THE UTERUS. 

Definition. — This term has been applied by Prof. Simpson to 
an excessive involution, which by causing too great absorption, 
produces atrophy of the uterus. 

Pathology. — Little need be said on this point. It is merely an 
excess of action of a physiological process, which accomplishes 
much good when kept within proper limits. 

Causes. — These are not clearly denned, but it is probable that 
derangement of involution by inflammatory action is the chief. 

Symptoms. — The uterus sometimes becomes so atrophic that 
complete amenorrhoea is the result. At others great diminution 
in the freedom of the menstrual discharge is caused. In either 
case those numerous and grave symptoms dependent upon non- 
performance of the menstrual function, may develop themselves 
and prove extremely annoying. Even epilepsy may be thus 
engendered. 

Physical Signs. — Upon vaginal examination the uterus is dis- 
covered high up in the pelvis, very small, and so light that it 
will be lifted by the slightest touch. Conjoined manipulation will 
probably fail to detect the organ, or if it do so will demonstrate 
its small size. When the speculum is introduced and the cavity 
of the uterus measured by the probe, it will be found to be very 
much diminished. Someti mes, from the os externum to the fundus, 
the organ will measure only two inches. Ocular demonstration 
will likewise be afforded that the cervix is much smaller than 
normal and its canal less capacious. 

These means will usually be sufficient to determine the ques- 
tion of diagnosis. Should any doubt still remain, the uterus 
may be fixed by a tenaculum passed, through the speculum, into 
the tissue of the neck, and touch be practised by the rectum. 
This will define very perfectly the volume of the body. 

Differentiation. — Superinvolution can be confounded with no 
other condition than the undeveloped uterus, and from this the 



SUPERINVOLUTION OF THE UTERUS. 457 

rational history will at once differentiate it. The former comes 
on after perfect performance of menstruation and after parturition. 
The latter is associated with a long history of amenorrhcea or 
emansio-mensium, and does not connect itself as a sequel with 
parturition. 

Results. — The great evil resulting from this condition is scanty 
or absent menstruation and its accompanying train of symptoms, 
nervous derangement, hysteria, neuralgia, &c. 

Treatment. — This consists in local mechanical means calculated 
to develop the atrophied uterus, and general measures directed 
towards putting the system into as robust a state as possible. 

Once or twice a month a tent of sponge or sea tangle should be 
introduced and allowed to distend the uterus to its utmost capacity, 
in order to stimulate its growth. After this has been done for 
some months the probe will show an increase of length of the 
cavity, and an attempt at menstruation may be noticed at each 
period of ovulation. An intra-uterine galvanic stem may then 
be introduced and worn constantly, if it should not produce too 
much irritation. 

If it be possible to recognize the periods at which ovulation is 
accomplished, the sympathetic process of menstruation should be 
excited by passing a strong current of electricity through the 
uterus and ovaries, the use of irritant enemata, and the applica- 
tion of warmth and moisture to the pelvis and feet by means of 
hip-baths and pediluvia. 



CHAPTEE XXXY. 

FUNCTIONAL DISORDERS OF THE UTERUS. 

There are several functional disorders of the uterus which, 
though in themselves not diseases but rather symptoms, claim 
especial notice on account of their importance. Those which will 
occupy our attention are — 

Dysmenorrhoea ; 

Menorrhagia ; 

Metrorrhagia ; 

Amenorrhoea; 

Sterility ; 

Leucorrhoea. 

DYSMENORRHEA. 

Definition. — The process of menstruation accomplishes itself by 
two stages, first, great congestion and rupture of the vessels of 
the circumference of the ovaries and at the same time of those of 
the uterine mucous membrane ; second, escape of the blood thus 
collected in utero through the cervical canal into the vagina. 

When all the elements connected with this process are in a 
perfectly normal state both these parts of it occur without creat- 
ing other discomfort than a sense of fulness about the pelvis, 
slight pain in the back and loins, and a general sense of lethargy. 
But if an abnormal condition should exist, either in the structure 
from which the blood pours into the uterus, in any of the sur- 
rounding parts or organs which undergo congestion, or in the 
canal by which it passes into the vagina, menstruation often be- 
comes excessively painful and in some cases undermines the health 
by the intensity of suffering which it induces. This state receives 
the name of dysmenorrhoea, a term derived from Si> ? , difficult, u^», 
a month, and p*w, I flow. 

Pathology. — Any condition, whether general or local, affecting 
the structure of the uterine walls, the ovaries, or the surrounding 



DYSMENORRHEA. 459 

areolar or serous tissues, so as to render the nerves supplying these 
parts morbidly sensitive, may produce pain in connection with 
the first part of the process. Anything interfering with an 'escape 
of blood from the uterus or vagina may produce it by interference 
with the second part. For example, a general condition resulting 
in neuralgia of the uterine or pelvic nerves, or a local inflamma- 
tion altering their state might readily create pain in the first stage, 
while either a natural or acquired stricture of the cervix would 
probably complicate the second in the same way. 
Varieties. — Dysmenorrhoea has been divided into — 

Neuralgic dysmenorrhoea; 

Congestive " 

Inflammatory " 

Obstructive " 

Membranous " 

Seat of Pain in Dysmenorrhea. — Upon this point our know- 
ledge is not certain. It is probable that in the first three varie- 
ties the pain may be seated in the uterus, in the ovaries, or in 
the cellular tissue or peritoneum surrounding the pelvic viscera. 
Some of the most intractable cases with which I have met have 
been due to pelvic peritonitis or cellulitis, which, even after 
inflammatory action has subsided, has left the nerves supplying 
these parts in so sensitive a state that pain is excited in them by 
the process of menstrual congestion. It is often very difficult to 
decide as to the exact seat of pain, and a physical exploration 
instituted during the period will fail to enlighten us. 

The practitioner who regards dysmenorrhoea as a disease, and 
applies to every case a uniform plan of treatment, can never 
meet with success in its management. Each case should be 
viewed as a symptom of an abnormal condition which should be, 
as far as possible, discovered and removed; and although even 
when acting thus, instances will occur in which he may be baf- 
fled, it will be gratifying to perceive how rare these will be. 
The great importance of differentiating the varieties mentioned, 
and adopting appropriate plans of treatment, calls for a separate 
study of each. 

Neura Igic Dysm enorrhoea . 

This variety depends upon no organic disorder of the uterus 
or its appendages, but merely upon a peculiar state of the 



460 FUNCTIONAL DISORDERS OF THE UTERUS. 

nerves, which, under the stimulating influence of congestion, 
produces pain. 

Caitses. — There is a variety of agencies which at times so alter 
the healthy state of the nerves of the stomach as to produce in 
them, at each period of digestion, pain, which is called gastralgia 
or gastrodynia. Similar agencies may result in neuralgia of the 
nerves of the eye, or those supplying the tissues of the head 
and face. In like manner they may affect the uterine nerves 
whenever they are inordinately excited from menstrual conges- 
tion. The same patient who from slight excitement or fatigue 
develops supra-orbital neuralgia, will often, from the same causes, 
suffer from neuralgic dysmenorrhoea. 

The causes which generally induce it are — 

The neuralgic diathesis ; 

Chlorosis or plethora ; 

Certain toxaemia, as malaria, gout, and rheumatism ; 

Luxurious and enervating habits ; 

Habits deteriorating the nervous system, as onanism or exces- 
sive venery. 

Symptoms. — The pain may show itself before the flow has been 
established, and disappear as soon as it comes on ; or it may con- 
tinue with varying intensity throughout the duration of the 
menstrual discharge. The patient complains of a sharp, fixed 
pain over the pelvis, down the loins, or in some distant part of 
the body. I once saw a patient who during each period suffered 
intensely from neuralgic pain on the outer side of one little 
finger, and I have one now who, before the flow is established, 
experiences for several days a violent pain at the root of the nose. 

Differentiation. — When the pain is felt in the uterus, it presents 
nothing expulsive in its character ; the flow of blood is steady, 
and not interrupted, and no clots are discharged by spasmodic 
efforts. These facts distinguish neuralgic from obstructive dys- 
menorrhoea. 

From the congestive form it is differentiated by absence of 
constitutional disturbance and suddenness of occurrence, and by 
its being habitual and not exceptional. It may be distinguished 
from the inflammatory variety, by absence of the ordinary signs 
of metritis, endometritis, ovarian, and peri-uterine inflammation. 



NEURALGIC DYSIENORRHffiA. 461 

There is absence of leucorrhoea, pain, &c, in the intervals of 
menstruation, as well as of the physical signs of inflammation. 

Prognosis. — If a patient affected by neuralgic dysmenorrhcea 
be able and willing to effect a decided alteration in her mode of 
life, the prospect of recovery is good. If no such change is 
attainable, it is decidedly unfavorable. 

Treatment. — The first duty of the physician should be to dis- 
cover the cause of the development of neuralgia in the perform- 
ance of the menstrual function, and the second to endeavor to 
remove this. Neuralgia of the face and head is rarely a primary 
affection, and consequently resists remedies directed especially to 
it. It generally results from some focus of irritation, as, for 
example, a decayed tooth, or a plug of hard wax in the ear, or 
from some blood poisoning ; and when the cause is removed it 
disappears. So with the disorder which we are investigating. 

If the rheumatic or gouty diathesis exist, it should be treated 
by colchicum, guaiac, and vapor baths. The skin should be kept 
warm and active by wearing flannel over the whole body in 
winter, and a mild, equable climate should be chosen during the 
cold months of the year. Should a delicate state of the nervous 
system have been engendered by habits of luxury, indolence, 
or dissipation, the patient should be sent to the country where an 
out-of-door life, horseback exercise, early hours of retiring, and 
plain, wholesome food may exert a sufficiently alterative influ- 
ence. Chlorosis and plethora should be treated, the one by ferru- 
ginous and nervous tonics, fresh air, food and cheerful surround- 
ings ; the other by strict diet, venesection, cathartics, and other 
depleting means. Malarial toxaemia should be treated by change 
of residence, quinine, and iron. A sea- voyage will often accom- 
plish an excellent result in neuralgic dysmenorrhcea by its alter- 
ative influence, whatever be the cause of the neuralgic state. 

In addition to these general means, benefit may be obtained 
from the use of some which are local. The occasional passage to 
the fundus of the uterus of a uterine sound or silver catheter, the 
retention in utero of the galvanic pessary, which will be described 
when speaking of amenorrhcea, and the use of tents of sponge or 
sea tangle, will often prove very serviceable. 

Parturition often accomplishes an excellent result, and in many 
cases cures the affection entirely. 



462 FUNCTIONAL DISORDERS OF THE UTERUS. 

Congestive Dysmenorrhoea. 

Definition. — At each menstrual epoch an active congestion oc- 
curs in the mucous membranes of the Fallopian tubes and uterus 
as Well as in the ovaries, and, probably, to a less degree in all the 
pelvic tissues. Should any abnormal influence render this exces- 
sive, it would naturally produce pain in the nerves intervening 
between the distended vessels. This has received the name of 
congestive dysmenorrhoea, which has been synonymously de- 
scribed as accidental dysmenorrhoea. 

Causes. — It may result from the following causes : — 
Plethora ; . 
Exposure to cold ; 
Sudden mental disturbance ; 
Sluggishness of portal circulation; 
Displacement of the uterus ; 
Fibrous tumors. 

Any one of these causes, without exciting true inflammation, 
may keep up a state of hyperemia in the uterine vessels, which, 
being augmented at menstrual epochs, creates pressure upon the 
neighboring nerves and consequently pain. 

Symptoms. — A patient who has previously menstruated pain- 
lessly is seized during a period with severe pelvic pain accompa- 
nied by diminution or cessation of the discharge and considerable 
constitutional disturbance. The pulse becomes full and rapid, the 
skin hot and dry, and the eyes suffused. There is severe pain in 
the head, with nervousness, restlessness, and sometimes, though 
rarely, a little delirium. There may be in addition rectal and 
vesical tenesmus and diarrhoea. 

Differentiation. — The constitutional disturbance and suddenness 
of the attack will mark its difference from the neuralgic and ob- 
structive forms, as the absence of signs of inflammation in the 
intervals will do from the inflammatory. 

The membranous has, of course, its distinctive sign in the 
cast of the uterine cavity. 

Prognosis. — Unless the cause for the disorder be the existence 
of an obstinate displacement or of a fibroid, the prognosis is 
always favorable. 

Treatment. — As in the neuralgic variety, the source of the evil 



INFLAMMATORY D YSMENORRHGE A . 463 

should be carefully ascertained before remedial measures are 
adopted. If it be due to plethora, the lancet, cathartics, strict diet, 
exercise, and fresh air will be indicated. Should the attack be 
accidental and have occurred from exposure to cold and moisture, 
opiates, diaphoretics, and sedatives will give speedy relief. In 
case a sluggishness of the portal circulation exists, this should be 
stimulated to greater energy by mercurial cathartics and a change 
in the habits of life from sedentary to active. A displaced uterus 
is often kept in a constant state of congestion, which can be 
relieved only by properly sustaining the organ. If a fibrous 
tumor be the cause, a cure will depend upon its susceptibility of 
removal. 

Inflammatory Dysmenorrhea. 

Definition. — In the great majority of instances inflammation of 
the uterine mucous membrane or parenchyma is the cause of 
dysmenofrrhoea. The existence of disease in these parts causes, 
perhaps, little pain until the erethism engendered by menstrua- 
tion occurs. Then great local excitement takes place and dys- 
menorrhcea shows itself. 

Causes. — It may result from almost any pelvic inflammation. 
More especially it is connected with — 
Endometritis ; 
Metritis ; 

Peri-uterine cellulitis ; 
Pelvic peritonitis ; 
Ovaritis. 
Symptoms. — As the flow begins, or before that time, the patient 
suffers from dull, heavy, fixed pelvic pain, which lasts until the 
process is ended, and often even after it has done so. 

Differentiation. — It may be differentiated from the other varieties 
alluded to, by pain during the intervals, leucorrhoea, inability to 
make exertion, and absence of the positive signs attending the 
other forms. 

Prognosis. — This will depend upon the prognosis of the inflam- 
mation which has given rise to it. If this can be removed, the . 
dysmenorrheas, which is one of its symptoms, will disappear ; if 
not, it will continue without material diminution. 



464 FUNCTIONAL DISORDERS OF THE UTERUS. 

Treatment — Little need be said upon this point, for treatment 
must be directed not to one symptom but to the disease which 
produces the whole train. If the root of the evil be metritis or 
endometritis of neck or body, appropriate treatment must be 
directed to these affections. If ovaritis or cellulitis be the appa- 
rent cause of the difficulty, these diseases must receive attention. 

Obstructive Dysmenorrhea. 

If, after the collection of blood in the uterus, any obstruction 
exists which prevents its escape into and through the vagina, a 
violent spasmodic pain is excited which often amounts to ute- 
rine tenesmus. To this form of painful menstruation the name of 
obstructive dysmenorrhoea has been applied. The obstruction 
may exist in the os or cervix uteri, in the vagina, or at the 
vulva, where that canal is partially closed by the hymen. 

Pathology. — If any organ be filled with fluid beyond the point 
of tolerance, as, for example, the bladder, stomach, or la^ge intes- 
tine, violent contractions of the distended fibres which make up 
its walls are excited, and spasmodic efforts, which have received 
the name of tenesmus, are established. If evacuation results from 
these, relief is obtained; if not, they continue for a long time. 
When occurring in the uterus, they present the symptoms which 
make up the affection which now engages us. 

Causes. — The special causes of such obstruction are — 

Contraction of the cervical canal ; 

Flexion or version of the uterus ; 

Vaginal stricture ; 

Small polypus in utero ; 

Obturator hymen ; 

A fibroid in the parenchyma of the neck. 
Any one of these may produce the result by partially occlud- 
ing the cervical canal, so as to allow an escape of fluid imperfectly 
and painfully. Contraction of the cervix may be congenital, or 
may result from inflammation of the mucous lining of the canal, 
diminution of its calibre by contraction of lymph poured out into 
.the parenchyma, or from the use of strong caustics within the os. 
The last cause is a prolific one, the condition seldom failing to 
result from the passage of the actual cautery or potassa cum calce 
into the canal of the cervix. Flexion obstructs the canal by 



OBSTRUCTIVE DYSMENORRHEA, 



465 



Fig. 181. 




Flexion productive of dysmenorrhoea. 



creating an angle in its course. Let a tube of gutta-percha be 

slightly curved and no obstruction will exist, but if it be sharply 

bent upon itself, complete occlusion 

will occur. Fig. 181 will make this 

clear. 

Versions much more rarely pro- 
duce the difficulty, but sometimes, 

the os being, by means of the dis- 
placement, pressed very firmly 

against one wall of the vagina, a 

partial obstruction is produced. 
Some months ago a young girl 

presented herself at my clinique, 

at the College of Physicians and 

Surgeons, declaring that at every 

menstrual epoch she suffered from 

the most intense bearing down 

pains, which exhausted her greatly. 

Upon examination I found a partial closure of the vagina, the 
result of sloughing during typhus fever, which had produced an 
accumulation of blood above it. This excited uterine contraction, 
and each effort caused the expulsion of a small amount of the fluid 
collected above the stricture. In like manner the hymen may 
prevent free escape and produce uterine tenesmus. 

Sometimes a small polypus comes down to the os internum and 
rests upon it, obstructing the egress of fluid, but permitting the 
passage of a probe into the uterine body. It acts upon the prin- 
ciple of the ball valve, and by so doing produces the worst fea- 
tures of obstructive dysmenorrhoea. 

Symptoms. — After menstruation has continued for some hours, 
and sufficient blood has been collected in the uterus to distend it, 
a severe spasmodic pain occurs over the pelvis, which has been 
styled " uterine colic." This rapidly passes into a violent expul- 
sive effort like the contractions attending miscarriage, which in 
time causes the passage of a certain amount of blood. Then all 
pain ceases for a time, until further obstruction and distension 
occur, when the process by which the uterus empties itself is 
repeated. 
80 



4:66 FUNCTIONAL DISORDERS OF THE UTERUS. 

It will be clear to tlie observer that the difficulty develops itself 
by these steps : — 

1st. Some obstruction causes collection of blood above it ; 
2d. This excites uterine contraction by distension ; 
3d. Distension to a limited degree frees the uterus and gives 
ease. 

This is the pathology of the condition, whether the obstruction 
exists in the vagina near the vulva, or in the cervical canal. If it 
exist at the latter point, the efforts of the uterus will generally 
expel first a small clot, and then a gush of imprisoned blood will 
follow, much to the patient's relief. 

Differentiation. — The symptoms just related are so marked and 
decided that little difficulty will generally be experienced in deter- 
mining as to the pathology of the case. Before such a decision 
is arrived at, however, physical exploration must place the matter 
beyond a doubt. The absolute obstruction must be demonstrated 
by difficulty in the introduction of a probe into the cavity of the 
uterus. Should the obstruction exist in the vagina, the finger 
will detect it, and if in the cervix, the probe will do so with almost 
as great precision. 

Prognosis. — This will depend entirely upon our ability to over- 
come the mechanical obstacle. Should it not be possible to re- 
move this, the constantly repeated distension of the uterine cavity 
and consequent effort required for emptying it, will frequently 
result in endometritis. 

Treatment of Cervical Constriction. — Should it be discovered that 
the cause of difficulty consists in congenital or acquired constric- 
tion of the cervical canal, the condition may be remedied by two 
methods, dilatation and incision, the means for accomplishing 
which may be thus presented at a glance : — 
Dilatation. 

By sounds; 
By tents ; 

By expanding instruments. 
Incision. 

Simpson's method ; 
Sims's method ; 
Combined method. 



OBSTRUCTIVE D YSMENOKRH(E A. 467 

In cases of cervical constriction the narrowing of the canal is 
much more marked at the os externum than at any other part, 
though in some instances the cavity of the neck may be con- 
stricted even up to the os internum. 

About the year 1832, Dr. Mackintosh, of Edinburgh, established 
the practice of # dilating such canals by metallic bougies, as is done 
in stricture of the urethra. His plan was to introduce a very 
small sound, leave it for a short time in position, and then follow 
it by others gradually increasing in volume. He declares, in re- 
porting upon the practice, that out of twenty-seven cases, twenty- 
four cures were effected. The sounds by which dilatation may be 
best accomplished are represented by Fig. 182. They consist of 
hard rubber, are of twelve graduated sizes, and may, by boiling 
in water, be bent to any curve which is found desirable to effect 
an entrance through the os internum. Dilatation by their means 
should be slowly and cautiously accomplished. A sound being 
passed should be left in position for fifteen or twenty minutes, 
and upon its removal another should be inserted, until the dis- 
tension deemed practicable at one sitting is attained. 

Fig. 182. 




Sounds of hard rubber or metal for dilating the cervix. 

There can be no question as to the efficacy of the plan, though 
it is probable that some of the cases relieved by Dr. Mackintosh 
were instances of neuralgic and not obstructive dysmenorrhea. 
Although it may be effectual I should not recommend its employ- 
ment, because it is tedious, painful, and uncertain, and because 
we have other methods which are far superior to it. Should it 
be determined to essay dilatation, the use of tents of sponge or 
sea tangle is preferable to the plan just alluded to. They should 
be employed once a week until the required dilatation is attained. 

But even this means fails very generally, and in place of it 
rapid dilatation by instruments, which are represented by that of 
Dr. Priestly, Fig. 183, has been advised. Their action is too inju- 



468 



FUNCTIONAL DISORDERS OF THE UTERUS. 



rious to the tissues, however, to be safe, and they are by no means 
so promising of good result as the use of cutting instruments. 

Fig. 183. 




Priestly's dilator for the cervix. 

In 1843 Prof. Simpson, of Edinburgh, advocated and practised 
cutting through the walls of the cervix, and thus gaining space 
without dilatation. He employed a single-bladed hysterotome, 
represented in Fig. 184. 

Fig. 184. 




Simpson's hysterotome. 

This instrument is introduced without a speculum, the patient 
lying on her left side. The metrotome, with its blade concealed, 
is guided by the index finger up to, and if necessary, as is very 
rarely the case, through the os internum. If the cervical canal 
be too small to admit it, previous dilatation should be practised 
by tents. Being placed in position the blade is thrown out, the 
force being increased as it is withdrawn to the os externum. By 
thus increasing the pressure upon the handle of the blade, the 
incision is made wider at the lower than at the upper part of 
•the canal. The instrument is then reintroduced and the other 
side incised in a similar manner, and the surface is brushed over 
with the solution of persulphate of iron. 

To accomplish the incision of both sides simultaneously Mr. 
Stohlman, of this city, has added a second blade, as is represented 
in Fig. 185. 

Since Dr. Simpson introduced this plan of treatment a variety 
of procedures has been recommended, but very little improvement 
had been attained until the introduction of Dr. Marion Sims's 
method. This consists in the following steps : — 



OBSTRUCTIVE D YSIENOKRHffi A . 469 

Fig. 185. 




Stohlman's hysterotome. 

1st. The patient is placed on the left side and the speculum 
introduced. 

2d. The uterus being fixed by a tenaculum, one wall of the 
cervix is cut with a pair of long scissors, one blade of which is 
passed into the cervical canal until the other passes nearly to the 
vaginal junction. In like manner the other wall is incised. 

3d. The blood being washed away by sponge probangs, a 
blunt-pointed knife, which can be placed at different angles with 
its handle by a movable joint, Fig. 139, is passed up, the tissue 
intervening between the ends of the scissors cnt, and the os inter- 
num severed on each side. 

4th. A roll of cotton saturated with glycerine is put into the 
wound, and a vaginal tampon applied. The operation is shown 
in Fig, 186. 

Fig. 186. 




Cervical hysterotomy. (Sims.) 



The patient is kept in bed for ten days after the operation. 
In twenty-four hours the tampon should be removed, and on 



470 FUNCTIONAL DISORDERS OF THE UTERUS. 

the third day the lips of the wound should be separated by a 
sound, and the cotton and glycerine dressing reapplied. This 
should then be done daily or the cervix will rapidly contract 
and become as small as before the operation. 

The results of incision of the cervix when practised in suitable 
cases is generally very gratifying. Where lymph has been poured 
out into the parenchyma, from cervical metritis, however, it is 
often impossible to keep the canal pervious. It gradually con- 
tracts in spite of all that can be done to oppose its doing so. 

A very simple and useful modification of the two operations 
described is to make an incision through the submucous layers of 
the parenchyma from the os internum through the whole course 
of the canal, and then dilate by sea-tangle tents. This may be 
done by introducing Sims's knife, or by such a hysterotome as 
that represented at Fig. 187. 

Fig. 187. 



White's hysterotome. 

This instrument was invented ten years ago by Dr. Octavius 
White, of this city, and has been frequently employed since by a 
number of practitioners. Being introduced up to the os internum, 
two blades are thrown out by an action governed by a screw at 
the end of the handle, and it is then withdrawn. After its removal 
a tent of sea tangle is introduced, and a wad of cotton applied so 
as to keep it in place. The tent need not be renewed oftener 
than every second day, and this should be repeated for seven or 
eight days. Dr. Arango informs me that he always employs a 
bit of gum elastic catheter instead of a tent, and with equally good 
results. 

Treatment of Cases Dependent upon Flexion or Version. — Should 
version be the cause of dysmenorrhcea, it should be relieved by 
the means already mentioned when speaking of that displacement. 
If, as is much more generally the case, the difficulty be due to 
flexion, and more particularly to anteflexion, two indications offer 
themselves for its relief: 1st, to straighten the bent canal by 
keeping the body of the uterus erect ; 2d, to effect the same end 



MEMBRANOUS DYSMENORRHCEA. 471 

by surgical operation. The first of these indications is practicable 
only by the use of the intra-uterine stem pessary, which is often 
too dangerous to be admissible, and hence the second alone is 
usually at our command. 

If a uterus be flexed, as represented in Fig. 181, it is evident 
that obstruction to the menstrual flow will occur at the point of 
flexure, and equally evident that an incision through the sides of 
the canal would not overcome this by straightening it, while a 
single incision through the posterior wall would do so. In 1862 
Dr. Sims conceived and practised such an operation successfully. 
This will be found described in Fig. 140. It is unquestionably 
the procedure most applicable to the relief of dysmenorrhoea 
due to flexion, but it will probably never be employed except 
in anteflexion. Ketroflexion is so commonly the consequence of 
metritic inflammation that the danger of reestablishing this will 
contraindicate the operation. 

Treatment of Vaginal Stricture. — This condition, which may be 
congenital, or induced by syphilitic or cancerous disease, or by 
sloughing, if so complete as entirely to obstruct the canal, pro- 
duces amenorrhcea. If it be a pervious stricture, it may result in 
dysmenorrhoea. 

The affection may be treated by three methods : dilatation by 
large bougies, dilatation by tents, and incision. At the same 
time constitutional means should be resorted to, if syphilis be 
discovered as the basis of the local disorder. 

Treatment of Dysmenorrhea from Polypus. — Should the presence 
of a small polypus be discovered, the cervix should be dilated by 
tents and the growth removed. 

Treatment of Obturator Hymen and Fibroids. — The first should 
be freely incised, and the second if possible removed. 

Membranous Dysmenorrhoea. 
Concerning this variety we know very little with reference 
to etiology, course, or treatment. Our want of precise know- 
ledge depends upon the fact that the true pathology of the con- 
dition is not settled. Some, with Oldham and Tilt, regard it as a 
result of ovarian disease; others, with Eaciborski, 1 Lebert, Hand- 

1 Simpson, Dis. of Women, p. 101. 



472 FUNCTIONAL DISORDERS OF THE UTERUS. 

field Jones, and Simpson, look upon it as a pure desquamation 
or exfoliation of the uterine mucous membrane for which no 
cause can be assigned ; while Klob and others are convinced that 
it is an exudation, the result of endometritis. I have met with 
it but twice. In one case endometritis existed very severely ; in 
the other no uterine or ovarian disorder was discoverable. 

Symptoms. — The pain occurs in the commencement of men- 
struation, and ends only with the discharge of the exfoliated 
membrane. This membrane is pathognomonic of the kind of 
dysmenorrhoea which exists, and serves to differentiate it clearly 
from all other varieties. The appearance of the membrane is 
represented in Fig. 188. 

Fig. 188. 




Dysmenorrhoeal membrane. (Simpson.) 

Prognosis. — The prognosis as to cure is extremely unfavorable. 

Treatment. — Uncertain as we are as to the pathology of the 
disorder, little can be said of treatment. If uterine or ovarian 
inflammation be detected, it should be treated in accordance with 
general rules. If no such cause for the exfoliation be discovered, 
applications of alterative character may be made to the uterine 
mucous membrane, as tincture of iodine, chromic or carbolic acid, 
nitrate of silver, or solution of persulphate of iron. 



CHAPTEE XXXVI. 

MENORRHAGIA AND METRORRHAGIA. 

Definition. — The first of these terms is employed for the desig- 
nation of a profuse and excessive flow of blood at the menstrual 
periods ; the second for a steady flow of blood, whether profuse 
or not, during the intervals. A patient who menstruates too 
profusely is said to suffer from menorrhagia, while one who loses 
blood not only at menstrual periods but continuously,- is said to 
suffer from metrorrhagia. 

Frequency. — Both forms of the affection are necessarily fre- 
quent, for they are both symptomatic of a large number of 
organic affections of the uterus. 

Pathology. — Anything which induces a state of active or pas- 
sive congestion of the parenchyma or mucous membrane of the 
uterus, or any growth, which having a vascular connection with 
that organ, allows a flow of blood from its own surface, may pro- 
duce one of these disorders. 

Causes. — The conditions which most frequently occasion both 
these forms of uterine hemorrhage are — 

Congestion ; 

Inflammatory engorgement or hypertrophy ; 

Polypus ; 

Ulceration ; 

Fibrous tumors; 

Cancer ; 

Retained products of conception ; 

Fungous degeneration of uterine mucous membrane ; 

Inversion of the uterus ; 

Hematocele ; 

Subinvolution. 
Congestion of the uterus is very common at the period of the 



■■ 



474 MENORRHAGIA AND METRORRHAGIA. 

menopause, or as a result of violent muscular efforts. It may 
likewise occur as a consequence of abortion, an impeded hepatic 
circulation, commencing metritis or inflammatory hypertrophy. 

Ketention of some of the products of conception is very fre- 
quently a cause. The placenta may remain unaltered, the foetal 
envelope may become a mole, or the chorion may undergo de- 
generation, and uterine hydatids, as they are erroneously called, 
collect within the uterus. 

Fungous degeneration of the lining membrane of the uterus is 
not an infrequent source of both varieties of hemorrhage. The 
vegetations thus created, which consist in an hypertrophy of the 
mucous membrane, were described by Recamier, who advised and 
practised scraping them off by means of a steel instrument. 

M. Aran, who has written a most excellent article upon them 
in his work on the Diseases of the Uterus, thus describes them. 
" They present themselves in two entirely different forms. In the 
first and most common form they are tumors, ordinarily sessile, 
continuous with the mucous membrane by a base sometimes as 
large as themselves. They vary in size from that of a grain of 
wheat or a little pea to that of a large pea and even of a small 
strawberry or a large raspberry. The last are often pediculated." 
These are styled cellulo-vascular vegetations and may exist in 
any part of the cavity of the uterus. Generally they do not 
exceed two or three in number, and are found in the cavity of the 
body. " In the second form they are a species of pediculated 
vegetations resembling in appearance those follicular polypi 
which are so common in the neck of the uterus. They vary 
in size from that of a grain of wheat to that of a pea." These 
are called cellulo-fibrous vegetations. Both varieties generally 
result from chronic inflammation of the mucous lining of the 
uterus and their presence has given rise to the appellation of 
hemorrhagic metritis, as descriptive of certain forms of uterine 
inflammation attended by metrorrhagia. 

It is astonishing to perceive how profuse and constant a flow 
will sometimes result from very small and apparently insignificant 
vegetations. Some years ago I had an opportunity of examining 
post-mortem a patient of Dr. Louis Elsberg, of this city, of whom 
this history was given. The patient had suffered for years from 
menorrhagia and occasionally from metrorrhagia. On many 



DIFFEKENTIATION. 475 

occasions Dr. Elsberg had resorted to the tampon, and on several 
had been forced to ping the cervix with considerable force to 
prevent death from the excessive flow. Upon inspection I fonnd 
nothing to account for the condition but three fungous projections, 
which were situated just above the os internum. They resembled 
somewhat the warty growths sometimes seen upon the glans 
penis, except that their papillary character was not so marked. 
Unfortunately they were destroyed before they could be exa- 
mined by the microscope. It may be suggested that some other 
cause might have existed, but none such was discovered upon 
careful investigation. The uterus, ovaries, and pelvic tissues 
appeared to be in a perfectly normal condition. 

Differentiation. — This is at once the most important and most 
difficult of the physician's duties in reference to the symptoms 
which we are considering. If he be too easily persuaded to look 
upon the loss as one of the results of the " change of life," or even 
of primary idiopathic congestion, much time may be lost before 
his error is corrected. If he forgets that he is dealing with a 
symptom, and looks upon the condition as a disease, he will often 
not merely lose time, but, in the end, entirely fail in giving relief; 
for the empirical practice of confining such patients to bed and 
relying upon astringents, cold applications, and narcotics will 
generally be found to be ineffectual. 

In every case, unless the cause be palpable, it is advisable to 
examine systematically the entire uterus and its surrrounding 
tissues in the following manner : — 

1st. The cervix should be investigated by touch, the speculum, 
and the uterine probe ; 

2d. By conjoined manipulation, palpation, and rectal touch, the 
anterior and posterior walls, and the fundus and sides of the uterus 
should be examined ; 

3d. The whole pelvis should be explored by conjoined mani- 
pulation, rectal touch, and palpation ; 

4th. The cervix should be dilated by tents, and the cavity of 
the body explored by the introduction of the index finger and by 
the uterine probe. 

In many instances a diagnosis can only be made by those 
means; but by their aid, if fully developed, very few cases will 
baffle research. 



476 MENORRHAGIA AND METRORRHAGIA. 

Tents offer us a most valuable means for diagnosis and treat- 
ment, but the practitioner must be very sure to open the os inter- 
num by them so that the ringer may pass to the fundus. In many 
cases when it is supposed that a full investigation of the uterine 
cavity has been made, the os internum has never been passed by 
the finger, which consequently explores only the cervical canal. 
It will not infrequently require three and even four tents to open 
the cavity of the body fully to the finger. 

Prognosis. — This will depend upon the cause of the affection. 
Should it be clearly ascertainable and curable, it will, of course, 
differ very much from what it would be if the opposite facts 
obtained. 

Results. — Menorrhagia, and more markedly still, metrorrhagia, 
if unchecked, may result in — 
Sterility ; 
Hydremia ; 
Hysteria ; 
Dyspepsia ; 
Extreme emaciation ; 
Death. 

Treatment. — This is palliative and curative. The treatment of 
a profuse flow of blood from the uterus, as from any other part 
of the body, should always consist primarily in checking it. 

In a case of menorrhagia, the patient should be kept perfectly 
quiet upon her back ; cloths wrung out of cold water should be 
laid over the uterus, vulva, and thighs ; cold, acidulated drinks 
should be given freely ; and the ingestion of all warm fluids 
strictly interdicted. In addition the apartment should be kept 
cool, the nervous system quieted by opium, or an appropriate 
substitute, and all conversation prohibited. 

In mild cases this may suffice, but in severe ones it will not. 
Then the speculum should be introduced and a sponge tent 
passed into the cervix and the vagina filled with a tampon. This 
will rarely fail. But in certain cases, as, for instance, those of 
cancer of the neck, the tent will not be admissible. Under these 
circumstances a soft sponge or wad of cotton should be saturated 
with solution of the persulphate of iron, laid upon the cervix, 
and the tampon placed against it ; or a small linen bag may be 
filled with powdered alum, placed in contact with the cervix, 
and held in place by a tampon. To these means almost all 



TKEATMENT. 477 

cases will temporarily yield, more especially if the use of the tent 
be admissible. 

Curative Treatment. — Before a case of menorrhagia is subjected 
to this course of management, this point must be carefully con- 
sidered: some women naturally flow very freely at menstrual 
epochs, and are not injured by the loss. It is their peculiarity 
and not an evidence of an abnormal state, and it should be 
decided whether or not treatment is required. 

In reference to metrorrhagia, it is equally important to bear in 
mind that some women, during the early months of pregnancy, 
have a steady flow of blood, and before a tent is employed, or 
probing the uterus is resorted to, this state should be carefully 
eliminated. 

If the existence of congestion, polypus, ulceration, fibroids, 
cancer, inversion, hematocele, retention of products of concep- 
tion, subinvolution or inflammatory hypertrophy, be ascertained 
to be the cause of the hemorrhage, the curative treatment of the 
symptom should be entirely subordinated to that of the disease 
which produces it, and as those affections have been elsewhere 
investigated, the reader is referred to other parts of this work for 
rules for their management. It may be well to state here that in 
the case of subinvolution, the free use of ergot will be found a 
valuable adjuvant to the means already enumerated for palliative 
treatment, and that it may prove serviceable in that which is 
curative. In the treatment of congestion the occasional use of 
an active mercurial purgative or the systematic and steady em- 
ployment of the same class of medicines in small doses will often 
prove highly beneficial. 

Treatment of Fungous Degeneration of the Uterine Mucous Mem- 
brane. — If this condition be clearly diagnosticated, not surmised, 
but absolutely ascertained by the touch to exist, the whole uterine 
canal should be fully dilated at intervals of about a week, in the 
hope that pressure from the tents will cause an atrophy of the 
morbid growths. Should this plan, persisted in for three or four 
months, fail, full dilatation should be secured and the whole 
mucous lining of the uterus scraped gently by one of the curettes, 
represented in Figs. 189 and 190, until touch proves it to be 
entirely free from vegetations. 

After this, at intervals of a week, the cervix should be dilated 



478 MENORRHAGIA AND METRORRHAGIA 

Fig 189. 



C. T1EUAHH-CO. 

Ilecarniers curette. 



Fig. 190. 




Sinis's curette, representing the angles at -which it may he hent. 

arid the whole cavity painted freely over with solution of persul- 
phate of iron; a strong solution of nitrate of silver ; or the tincture 
of iodine, according to Dr. Churchill's formula. After dilatation 
of the neck it is not dangerous to inject into the cavity of the 
body any of the fluids just mentioned, as they flow out imme- 
diately, and this plan may be resorted to. Thus employed, the 
solution of iron and tincture of iodine should be diluted with one- 
half or two-thirds of water. 

Empirical Treatment of Menorrhagia. — Sometimes we are called 
upon to treat this condition empirically, in consequence of the 
fact that all our efforts have failed to enlighten us as to its cause. 
At the same time that I would inveigh against such a course 
being inconsiderately followed, I deem it best to point out the 
general plan of management which would be most appropriate 
under such circumstances. 

The patient should be required to lead a plain, simple life, to 
keep as much as possible in the open air, and to avoid stimulating 
food and beverages. Should plethora exist, the blood should be 
attenuated by diet, exercise, and the lancet. The bowels should 
be kept perfectly regular and the skin active. The whole uterine 
canal, from os to fundus, should be repeatedly dilated, in the hope 
of producing an alterative action upon the mucous membrane, 
and subsequently injected or painted with tincture of iodine, solu- 
tion of persulphate of iron, tannin and glycerine, or nitrate of sil- 
ver. This should be repeated at appropriate intervals. At the 
same time astringents and acids should be administered, and in 
case of uterine enlargement ergot should be given. 



CHAPTEE XXXVII 



AMENORRHEA. 



Definition. — Amenorrhea, a term derived from a, privative 4 , wv, 
" a month," and psa, " I flow," implies an absence of the menstrual 
flow in a woman in whom it should naturally exist. Such an 
absence before puberty, after the menopause, or during pregnancy, 
is the normal condition, and hence does not come within the defi- 
nition. 

Frequency. — It is an affection of great frequency among women 
who lead luxurious and indolent lives, and disorder the nervous 
and sanguineous systems, by neglect of those habits which keep 
them in a state of health. Hence it is very frequently encoun- 
tered among the members of the higher classes of civilized society 
all over the world. 

Varieties. — If the habitual monthly discharge is suddenly 
checked, the disorder is styled suppressio-mensium, and if the 
discharge has never appeared in a woman who ought to menstru- 
ate regularly, it is called emansio-mensium. 

Pathology. — That the discharge of blood which, occurring at 
monthly periods constitutes menstruation, is a true hemorrhage 
dependent upon the process of ovulation, is now regarded as a 
settled fact by mos 1 progressive physiologists. In accordance 
with a law of nature which we recognize in its effects but cannot 
explain, once in every twenty eight days one or more ovules 
in each ovary burst their envelops, and entering the Fallopian 
tubes pass downwards to the uterus. This eruption of ovules 
produces in the ovaries, congestion and nervous exaltation, which 
continue until the process is completed. 

No sooner are these organs thus affected than, through the in- 
strumentality of the ganglionic system of nerves connecting them 



480 AMENORRHEA. 

with the uterus, that organ sympathetically undergoes congestion 
likewise. The whole uterus becomes heavy and descends per- 
ceptibly in the pelvis; its mucous membrane is swollen and 
turgid, and the vessels which supply it dilate under an exces- 
sive hyperemia, as do those of the conjunctiva in conjunctivitis. 
Then a rupture occurs and relief is obtained by hemorrhage. 
For the proper performance of the function three elements must 
exist in a perfect state of integrity : 1st, the uterus, ovaries, and 
vagina must] be perfect in form and vigor; 2d, the blood must be 
in its normal state; and 3d, the nervous system governing the 
relations between the uterus and ovaries must be unimpaired in 

tone. 

Any influence disordering one or more of these may check 
ovulation, the great moving cause of the function ; prevent the 
degree of sympathetic congestion necessary for rupture of uterine 
vessels ; or oppose the discharge of blood which has been effused. 
The non-performance of the function of menstruation was 
formerly, and even now is by some, regarded as productive of 
many constitutional evils, as, for example, chlorosis, phthisis, 
dropsical effusions, &c. It is highly probable that in these 
deductions the effect has been mistaken for the cause. The im- 
poverished blood, and nervous derangement attendant upon these 
affections, result in failure of the function. No proof exists 
which can substantiate the view that amenorrhcea ever induces 
serious organic lesion of any organ in the body. 

Causes. — After what has been already stated, the causes of the 
affection may be tabulated without fear of confusing the reader. 
Amenorrhcea may result from any of the following conditions: — 
Abnormal stales of organs of generation. 
Absence of uterus ; 
" " ovaries; 
Rudimentary uterus ; 
Occlusion of uterus ; 

" " vagina;. 

Metritis or endometritis ; 
Superinvolution ; 
Pelvic peritonitis ; 
Atrophy of both ovaries ; 
Cystic degeneration of both ovaries. 



CAUSES. 481 

Abnormal states of the blood. 
Chlorosis ; 
Plethora ; 

Blood state of phthisis ; 
" "of cirrhosis ; 
" " Bright's disease, &c. 
Abnormal state of ganglionic nervous system. 
Atony from mental depression ; 
" " indolence and luxury ; 
" " want of fresh air and exercise ; 
" " constitutional diseases, as phthisis, &c. ; 
Absence of stimulation from non-performance of 
ovulation. 
Complete absence of the internal organs of generation is by 
no means common, though a rudimentary condition is less rare. 
With reference to absence of the uterus, Scanzoni remarks : " On 
carefully analyzing the reported cases of entire absence of the 
womb, we find that almost always some rudiments of this organ 
still exist, so that authenticated and unquestionable instances of 
this anomaly are extremely rare." He further declares that he 
has never been able to authenticate a single case. I have seen 
one instance presented by Prof. I. E. Taylor, to the Obstetrical 
Society of this city, in which no trace of the uterus could be 
detected upon the closest scrutiny of the parts removed post- 
mortem. 

Absence of both ovaries is quite rare. They are more fre- 
quently found to be in a rudimentary condition resembling their 
foetal state. 

The vagina may be occluded by an obturator hymen, contrac- 
tion from inflammation and sloughing, or from congenital or 
acquired atresia. 

So likewise may the canal of the cervix uteri be congenitally 
or accidentally closed. 

What I have styled atony of the nervous system, has been 
well described by Prof. Hodge, of Philadelphia, under the name 
of sedation. It consists in a decrease of the excitability, vigor, 
and activity of the nervous agency which controls the functions 
of differ ent organs, and has for its cause physical and moral 
influences, some of which have been enumerated. Some of the 
31 



482 AMENORRHEA. 

functions which are under the control of the ganglionic system, 
are the action of the heart, digestion, peristalsis, and regulation 
of animal heat. In one leading a natural and healthy life, in 
the country, for example, all these are likely to be normally per- 
formed ; but if the same individual removes to a crowded city, 
leads the life of a student, exhausts his nerve power by late 
hours, bad air, and mental efforts, all of them rapidly become 
deranged. He suffers from palpitation of the heart, dyspepsia, 
coldness of hands and feet, and constipation. This change usu- 
ally occurs slowly, but sometimes it does so rapidly, as from a 
sea voyage or any very violent mental strain. In a similar 
manner the processes of ovulation and menstruation are affected 
by it, in some cases gradually, in others with great rapidity. 

Differentiation. — Before treatment is instituted for this condi- 
tion, it must be carefully differentiated from — 
Pregnancy ; 
The menopause ; 
Tardy menstruation. 

The first will be readily recognized by its characteristic signs, 
if suspicion be awakened, and they are investigated. Yery often 
no such suspicion arising, the criminal desires of some women 
are gratified, and the hopes of others blighted through the un- 
intentional induction of abortion by the treatment adopted. 

The law with regard to the menopause is, that it should occur 
between the ages of forty and fifty, but it is sometimes delayed 
until sixty or seventy, and at others takes place at a very early 
age. It may occur as early as the twenty-first year, and in 
twenty- seven out of forty-nine cases of early cessation collected 
by Dr. Tilt, 1 it took place from the twenty-seventh to the thirty- 
ninth year. The absence of sensations of discomfort at the 
periods when the menses should occur, will lead the practitioner 
to a correct conclusion as to the character of the case. 

Sometimes mothers will be much alarmed by absence of the 
function in girls of seventeen and eighteen years. It should be 
remembered that it is not very rare for it to be delayed until 
the twentieth or twenty-first year. Differentiation should be 
made in this case as in the last. 

1 On Uterine and Ovarian Inflammation, p. 54. 



TREATMENT. 483 

Treatment. — From what "has been already said, it is manifest 
that amenorrhoea is not a disease, but a symptom of some local 
or general disorder, and it follows that all efforts directed simply 
to re-establishment of the absent function, must necessarily be 
empirical. The cause should' be discovered, and, if possible, re- 
moved. Should it be susceptible of removal, the method appro- 
priate for accomplishing it will be evident, while if it depend 
upon an incurable condition, scarcely less benefit will be gained 
by the avoidance of means previously practised in the vain hope 
of establishing the flow, and by our ability to place the mind of 
the patient beyond the harassing influence of suspense. 

If the uterus be found to be absent, all that can be done will be 
to abstract a sufficient amount of blood from the arm by vene- 
section to relieve the urgent symptoms attending each epoch. 

Should metritis, endometritis, or peritonitis exist, they, and not 
one symptom which may attend them, should be treated. 

Occlusion of the vagina or cervix should be treated by surgical 
means, the barrier being overcome by the knife, scissors, or trocar. 

In case a rudimentary or atrophic uterus, or superinvolution 
is discovered as the source of the affection, the uterus should 
be developed by local stimulation and distension. Once every 
week or every two weeks it should be fully distended by a tent, 
in order that an increase of nutrition and consequent increase 
of volume and capacity may be excited. When this plan is not 
in operation, an intra-uterine galvanic pessary may be kept in 
utero for the furtherance of the same end. It is astonishing how 
much development may be obtained by a persevering practice of 
this plan. In many instances it will restore the uterus to its 
original size, and cause a return of the menstrual flow. But it 
often requires considerable time to bring about so flattering a 
result; even years may elapse before it is fully attained. 

If it be decided that the non-performance of the function is due 
to plethora or chlorosis, these states should be treated, the first by 
venesection, strict diet, exercise, and a life in the open air ; the 
second by change of air, rich food, exercise, and ferruginous 
tonics. In plethora, Prof. Bedford speaks highly of the abstrac- 
tion of blood from the arm at intervals of a month, the abstraction 
being performed between the menstrual epochs. 

Should some grave constitutional condition like tuberculosis 



484 AMENORRHGEA. 

or the others mentioned, be found to be the main morbid state, it, 
and not its resulting symptom, should attract attention. 

An atonic state of the nervous system governing menstruation 
should be treated by resort to a general tonic course. Among 
the means applicable to its removal may be especially men- 
tioned, exercise on foot and horseback, rowing, calisthenics, sea- 
bathing, nutritious food, and nervous tonics of medicinal cha- 
racter, as nux vomica, strychnine, quinine, and the general use 
of electricity. It is in this class of cases that many drugs and 
prescriptions styled emmenagogue have often succeeded in restor- 
ing the function even when used empirically. A state of general 
nervous atony is frequently attended by chlorosis and always by 
constipation. The nervous disorder and two of its resulting 
symptoms may be favorably affected by the stereotyped combina- 
tion of aloes, iron, and myrrh or nux vomica ; and the sluggish 
nerve power may be temporarily excited to the performance of its 
duties by the administration of tansy, rue, ergot, or savine. But 
it is not through desultory means of this character that a cure can 
with any confidence be anticipated. A more comprehensive plan 
directed to the improvement of the patient's constitution should 
be adopted and systematically pursued. As general means those 
already mentioned will always be found highly useful. If the 
patient while at home cannot be prevailed upon to practise suffi- 
cient self-denial to avoid what is injurious, or be made to develop 
the energy necessary to follow a course which requires effort, she 
may, with great advantage, be placed for a season in a well-regu- 
lated hydropathic establishment, where the early hours of retiring, 
simple food, exercise, society, pure air, and bathing will accom- 
plish a roborant effect which will prove of great value in the cure 
of the affection. 

But not only should constitutional means be adopted. After 
the general condition has been improved, local stimuli may be 
resorted to with great benefit. Those which will be found to be 
most efficient are : — 

Passage of the sound ; 

Tents ; 

Cupping ; 

Electricity ; 

Stimulating enemata ; 

Baths. 



TREATMENT. 485 

In their action these means probably exert an influence not 
only on the menstrual hemorrhage, but sometimes by their 
stimulating influence excite the process of ovulation. The sound 
should be passed up to the fundus once every day for three or 
four days before the expected flow, or if the process of ovulation 
does not demonstrate its existence, it may be passed once a week 
throughout the month. At the same periods tents of sponge or 
sea tangle may be used ; the former of which, from their irritating 
influence on the uterine mucous membrane, are preferable. 

The cervix uteri may, by the application of an exhauster or 
dry cup, have a marked hyperemia excited within it, which 
extends to the uterine body and replaces that which should have 
occurred from physiological causes. A very simple method for 
producing it is to inclose the neck within the mouth of the cylin- 
der of hard rubber represented in Fig. 191, and then exhaust by 
withdrawing the piston. 

Fig. 191. 




G. TIEISAHH~Ct: 

Syringe for dry cupping the cervix. 

Before the introduction of this instrument the uterus should 
be exposed by means of the cylindrical speculum. In this way 
I have repeatedly drawn, without effort, one or two drachms of 
blood through the mucous lining of the neck. 

Electricity is a means of some value. One pole of a battery 
may be applied over the lower portion of the spine and the other 
passed over the hypogastrium, placed in contact with the cervix, 
or even carried, by means of a wire covered, except for its terminal 
three inches, with a gum-elastic catheter, up to the fundus of the 
uterus. For the purpose of keeping up a mild but steady current 
within the uterus, Prof. Simpson has advised a stem composed of 
copper for one half its length and zinc for the other half, which is 
passed up to the fundus. It has an ovoid disk at its lower extremity 
upon which the cervix rests. Dr. Noeggerath has altered this 
with advantage, by having the stem composed of two parallel 
pieces of copper and zinc instead of two short pieces of these 
metals united at the centre of the stem. As these instruments 



486 AMENORRHEA. 

must be left in place while the patient walks about, there is always 
danger of their doing injury to the walls of the uterus and exciting 
inflammation. To avoid this I have employed a stem composed 
of alternate beads of copper and zinc, held together by a copper 
wire, which passes through the centre of each, and is secured to 
the uppermost and to the vaginal disk below. This may, by any 
movement of the woman, be bent at the required 

■pi- "I QO ' * 

angle, and consequently can do no injury. (Fig. 
192.) 

As an excitant of the menstrual flow, enemata 
of very warm water impregnated with chloride 
of sodium, aloes, or soap, constitute a valuable 
n . resource. Not only does the medicinal substance 

Galvanic pessary. _ J 

irritate the uterine nerves, but the warm fluid 
brought in close contact with the uterus excites a flow of blood 
to it. Hip-baths and pediluvia have long been resorted to for 
the purpose of exciting menstruation. They should be prolonged, 
and as warm as the patient can bear them. In addition to these 
means, copious injections of warm water may with benefit be 
thrown into the vagina, one or even two gallons being, by means 
of a proper syringe, projected against the os uteri. 

Eeasoning from analogy and from our knowledge of the phy- 
siology of menstruation, we are unquestionably warranted in the 
deduction that in a certain number of cases amenorrhoea is due to 
non-performance of the function of ovulation. It would be diffi- 
cult to give clinical evidence of the fact, but it might be strongly 
surmised, when none of the symptoms usually attendant upon it 
present themselves at monthly periods. The means by which it 
should be treated are those already advised, for any of the causes 
mentioned may produce that variety of the affection which is 
due to absence of ovarian, as they do of uterine functions. 



CHAPTEE XXXVIII. 

LEUCORRH03A. 

Definition. — This affection, the name of which is derived from 
xevxos, " white," and fc«, " I flow," consists in a whitish, yellowish, 
or greenish mucous discharge from the vagina. 

Synonymes. — It has been, in modern times, described under the 
names of fluor albus, blennorrhoea, pertes blanches, fleurs blanches, 
and whites. In ancient literature the variety of names which 
was applied to it may be judged of when it is stated that over 
fifty appellations were at different times employed in designating it. 

Frequency. — No disease nor symptom in the whole list of female 
ills is so common. Probably no woman ever goes through life 
without at some period, and for a variable time, suffering from it. 
It is only when it becomes annoying by its constancy, abundance, 
or irritating properties, that it attracts attention and causes the 
patient to seek assistance. 

History. — In the earliest writings of the Greek school and 
throughout Eoman and Arabian medical literature, abundant de- 
scriptions of this disorder may be found. Hippocrates described 
it, pointing out as among its symptoms, puffiness of the face, pale- 
ness, and enlargement of the abdomen. He evinces a familiarity 
with its treatment by an admission of the difficulty of curing it. 
Aretseus of Cappadocia, in the first century, mentioned the varie- 
ties of leucorrhcea, as to color, quantity, &c, and Aetius and Paul 
of iEgina speak of two forms of the affection, red and white flux. 
For the" latter, Aetius recommends gestation, vociferation, walk- 
ing, &c. The Arabians, Haly Abbas, and Alsaharavius, wrote 
upon the subject, but advanced nothing new. 

As in ancient times, so also in modern, it has attracted a great 
deal of attention, and until the establishment of the present school 
of Gynecology by Ee*camier, was treated of as a disease rather 
than as a symptom. Even long after this period it was commonly 



488 LEUCOKRHCEA. 

regarded as a disease ; as the result of constitutional debility ; or 
as the index of an impure blood state. For the views which are 
now entertained concerning it, we are indebted to no one so much 
as to Dr. J. H. Bennet, of London, who, by his forcible reasoning, 
supported by clinical evidence, clearly demonstrated its depend- 
ance as a symptom upon some local lesion. Dr. Tyler Smith, in an 
elaborate essay upon the subject, has also done much to elucidate 
certain points in its pathology, which before his time had been 
undeveloped. 

Pathology. — As a discharge of mucus or muco-pus is a symp- 
tom of urethritis, bronchitis, nasal catarrh, and faucitis, so is it a 
symptom of inflammation of the vagina and lining membrane of 
the uterus and Fallopian tubes. Whatever influence is capable 
of creating it elsewhere may give rise to it here, and in this posi- 
tion it is, as it is elsewhere, only an isolated sign of a pathologi- 
cal state. It is not by any means, however, always an evidence of 
inflammatory action. As many individuals upon exposure to 
cold will freely discharge mucus from the nostrils without any 
inflammation existing, so w r ill many women suffer from leucor- 
rhcea from any cause producing a temporary congestion of the 
mucous membrane. But in these cases the disease is temporary, 
following or preceding the menstrual congestion, or arising from 
fatigue or exhaustion. When it becomes permanent and the dis- 
charge grows profuse or acrid, its connection with a morbid state 
is rendered probable. At such times it is always a symptom of 
some abnormal condition of the uterus, Fallopian tubes, or vagina, 
and its presence should stimulate investigation of these organs. 

Any agency which moderately increases vascular activity in a 
secreting organ, tends to augment the amount of its secretion. I 
say moderately increases, because an excessive turgescence, such 
as attends upon acute inflammation, checks secretion entirely- 
Such an influence being exerted upon any part of the mucous 
covering of the generative canal of the female, an excessive flow 
of plasma, together with a rapid exfoliation of epithelial cells 
and the formation of pus-corpuscles results. 

Varieties. — Leucorrhcea is divided into two varieties, according 
to its origin, vaginal and uterine. Either of these may exist 
separately, or the two may coexist. If it be vaginal, it may con- 
tinue as such for a length of time, or pass upwards into the uterus 



VARIETIES 



489 



and tubes. If the inflammatory action producing the discharge 
be confined to the uterine mucous membrane, it may remain so 
without complicating the vagina, but that canal receiving the 
products of uterine secretion is generally excited into morbid ac- 
tion. A similar result may frequently be observed in nasal catarrh 
in children, the upper lip being bereft of its epithelial investment, 
and a papular or vesicular eruption excited over the neighboring 
parts of the face. 

Vaginal leucorrhcea consists of a white, creamy, purulent look- 
ing fluid, which consists, according to Dr. Tyler Smith, of the fol- 
lowing elements :- — 

Acid plasma ; 

Scaly epithelium ; 

Pus-corpuscles ; 

Blood-globules ; 

Fatty matter. 
Under the microscope it appears as represented in Fig. 193. 

Fig. 193. 




Vaginal leucorrhcea under the microscope. (Smith.) 

That arising from the canal of the cervix is thick, tenacious, 
and ropy, like the white of egg, and consists of — 
Alkaline plasma ; 
Mucous corpuscles ; 
Altered cylindrical epithelium ; 
Pus-corpuscles ; 
Blood-globules ; 
Fatty particles. 



490 



LEUCOREHCEA. 



Examined by the microscope it presents the following appear- 
ance (Fig. 194). 

Fig. 194. 




Cervical leucorrhoea under the microscope. (Smith) 



That arising from the body of the uterus resembles the cervical 
form, except that it is less gelatinous, less ropy, and more likely 
to be tinged with blood. But the secretion of uterine leucorrhoea, 
when acted upon by the acid secretion of the vagina, assumes a 
curdy appearance like boiled starch. 

Causes. — It has been customary to treat of the causes of this 
affection under two heads, constitutional and local. They may 
be more correctly appreciated by dividing them into those causes 
which produce it by creating congestion, and those by inflamma- 
tion, for no agency can result in it except in these two methods. 
Causes by congestion. 

Disordered menstruation ; 

Fibroids or polypi ; 

Prolonged lactation ; 

Rectal irritation ; 

Vesical irritation ; 

Gestation ; 

Parturition ; 

Excessive coition. 



TREATMENT. 491 

Causes by inflammation. 

Endometritis, corporeal or cervical ; 
Granular degeneration ; 
Ulceration ; 
Fibroids or polypi ; 
Epithelial cancer ; 
Gonorrhoea ; 
Inversion of the uterus. 
It will thus be seen that the disorder may in some instances be 
a trivial matter, which, by a judicious combination of general 
and local means, will rapidly disappear, while in many others it 
is merely an attendant circumstance of some grave pathological 
state of the uterus or vagina. 

Prognosis. — This will depend in great degree upon the cause. 
If this can be readily removed, the prognosis will be favorable ; 
while if it be connected with some serious organic lesion, it will 
not be so. 

Results. — Uterine leucorrhoea often results in — 
Sterility ; 
Vaginitis ; 
Pruritus vulvas ; 
Vulvitis. 
Dr. Tyler Smith, in the work just referred to, declares that it i 
is even the cause of parenchymatous inflammation, granular 
degeneration, and hypertrophy. It is much more probable that 
the endometritis which results in the discharge also produces, by 
extent of inflammation, the other diseases mentioned. 

Treatment. — The treatment of leucorrhoea should consist in the 
treatment of the disorder which has induced it. It should never 
be dealt with empirically. If a vaginal discharge exists, and an 
astringent injection is employed, it may effect a cure — but let the 
practitioner bear in mind, in using it, that he is treating by it 
either congestion or inflammation of the genital tract, and not 
one of the symptoms of these affections. 

The first care should be to determine whether the disorder is due 
to congestion or inflammation ; the second, whether it is uterine 
or vaginal. If it be vaginal, it may be relieved by injections ; if 
uterine, injections will do no good except in preventing vaginal 
implication. Should it be decided that the affection results from 



492 LEUCOREHCEA. 

vaginal disease of inflammatory type, the ordinary treatment for 
vaginitis, which has been elsewhere described, should be adopted. 
If it be regarded as due to a chronic congestion of the vaginal 
mucous membrane, tone should be given to its weakened and dis- 
tended vessels by astringent substances employed by injection. 
The best astringents for this purpose are the persulphate of iron, 
alum, tannin, infusion of oak bark, zinc, and lead. In cases in 
which astringents do not appear to effect a good result, emol- 
lients, as glycerine, boiled starch, infusion of linseed, slippery 
elm, or similar substances dissolved in water, will often prove 
beneficial. 

Should the attack be due. to congestion which has affected the 
uterus, that condition should be as far as possible removed by 
appropriate means. In case investigation proves that some 
uterine lesion, as, for example, endometritis, or granular degene- 
ration, has given rise to it, the existing disorder should receive 
attention. 

In the treatment of chronic inflammatory states of the uterus, 
it will often be found of benefit to use astringent injections. 
These act not only by securing cleanliness, but by hardening the 
vaginal mucous membrane and rendering it less liable to disease. 
To enter more minutely into the treatment, would be to defeat 
-the main object which I have had in view, that of subordinating 
the consideration of the disorder to that of the diseased states 
which produce it. 



CHAPTER XXXIX 



STERILITY. 



Definition and Synonymes. — This term, which is derived from 
tffepfoj, ■ " barren," and implies an incapacity for conception, is 
synonymously entitled Barrenness and Infecundity. 

History. — Throughout medical literature, from the earliest 
periods to the present, it has attracted special attention, and been 
the subject of dissertations by all authors who have touched 
upon the affections peculiar to females. The frequent reference 
made to it by biblical writers as a great misfortune to women, 
is too well known to require special mention. 

Causes. — To comprehend the pathology of sterility, the phy- 
siology of conception must be clearly understood. In the act 
of coition the male organ, being introduced into the vagina, pro- 
jects into and against the cervix a fluid, consisting of a thick, 
watery portion, holding in suspension large numbers of ciliated 
cells which have the power of moving by ciliary action. The 
bulk of this fluid pours down into the vagina, but many of the 
cells which it contains pass upwards into the body of the uterus, 
and through the Fallopian tubes as far as the ovaries. Should 
they come in contact with an ovule, impregnation may take place 
in the ovaries, Fallopian tubes, or uterus. When the impregnated 
ovule is received in the uterus, the mucous membrane of this 
organ undergoes exuberant development, and throws around it 
an envelope called the decidua reflexa. Further than this, the 
process does not concern us, for conception has now followed 
impregnation, fixation of the impregnated ovum having occurred. 

These facts being kept in mind, it becomes evident that a 
variety of influences may interfere with the performance of this 
delicate and subtle process. For its accomplishment three things 
are necessary — 



494 STERILITY. 

1st. The possibility of the entrance of seminal fluid into the 
uterus ; 

2d. The possibility of the entrance of an ovule into the uterus ; 

3d. The absence of influences destructive to the vitality of the 
semen and preventive of fixation of the ovule upon the uterine 
wall. 

Should these three conditions exist, no woman will be sterile. 
She might not bear children, but the incapacity may attach to the 
male and not to her ; or, having conceived, she may have suffered 
from consecutive abortions, which have been mistaken for attacks 
of menorrhagia. 

The special causes of sterility may be thus presented : — 

1. Absence of some essential organ. 

Ovaries ; 
Tubes ; 
Uterus ; 
"Vagina. 

2. Interference with passage of semen into uterus. 

Obturator hymen ; 

Vaginismus ; 

Atresia vaginas ; 

Occlusion of cervical canal ; 

Conical shape of cervix ; 

Cervical endometritis, or metritis ; 

Polypi or fibroids ; 

Displacements. 
8. Interference with passage of ovule into uterus. 

Obliteration of tubes; 

Displacement of tubes. 
4, Interference with vitality of semen, or fixation of ovule. 

Corporeal endometritis ; 

Membranous dysmenorrhea ; 

Menorrhagia ; 

Metrorrhagia ; 

Abnormal growths ; 

Vaginitis. 
The mode of action of most of these causes is so self-evident as 
to make anything more than their mention unnecessary. Some 
of them, however, require special explanation. 

Vaginismus is an appellation which has been given of late 



CAUSES. 



495 



Fig. 195. 



years to a hyper aesthetic state of the ostium vaginas, which results 
in spasm of its sphincter. This interferes with the entrance of 
the male organ, and consequently of seminal fluid into the vagi- 
nal canal ; indeed, in aggravated cases it entirely precludes sexual 
approaches. The affection is by no means rare, and is a fruitful 
source of sterility. 

An abnormal shape of the cervix has been pointed out by Dr. 
Sims as a frequent cause of infecundity. If this part be too long, 
so as to curl or bend upon itself, it is evi- 
dent that it may not admit seminal fluid 
through its canal. But even a slighter 
degree of elongation, in which the cervix 
has a conical shape, has been observed to 
be frequently followed by that condition. 
My own experience leads me very posi- 
tively to the conclusion that, excepting 
endometritis, this is the most common of 
all the causes, and fortunately one of the 
most remediable. Fig. 195 represents the 
variety of conoid cervix, generally met 
with as productive of sterility. 

Endometritis, whether it be cervical or corporeal, fills the ute- 
rine canal with a thick, tenacious mucus, which often prevents 
the entrance of seminal fluid. 

Displacements. Flexions, by sudden bending of the cervical 
canal, and versions, by pressing one wall of the vagina against the 
os so as to close it as if by a valve, may entirely obstruct the pas- 
sage to the uterus. Figs. 196 and 197 exhibit this very clearly. 




Conoid cervix. (Sims.) 



Fig. 196. 



Fig. 197. 





Flexion a cause of sterility. 



Version a cause of sterility. 



496 STERILITY. 

Obliteration and displacement of the tubes frequently result from 
pelvic peritonitis, and thus that affection often entails sterility of 
the most irremediable character. The second stage of the dis- 
ease consists in effusion of lymph, which in time undergoes con- 
traction, and either closes these canals or draws them out of place. 

Membranous dysmenorrhoea, or rather the tendency to exfolia- 
tion of uterine mucous membrane which characterizes it, so alters 
the uterine surface as to render it inapt for the fixation of the 
ovum. 

Menorrhagia and metrorrhagia may result in the washing away 
of the ovum after impregnation and before fixation. The normal 
menstrual hemorrhage occurs before the entrance of the ovule 
into the uterus. If it be excessive and prolonged, it may remove 
the ovule entirely, and in the same way metrorrhagia may re- 
move the impregnated ovum. An abortion does not occur under 
these circumstances, for although impregnation may have taken 
place, conception has not done so. 

Abnormal growths of any form which fill the uterine cavity, as, 
for example, fibroids, polypi, hydatids, or moles, may so interfere 
with the attachment of the ovum to the uterus, as to prevent 
conception even if impregnation has occurred. 

Differentiation. — Before it be determined that a woman is 
sterile, the sexual capacity of the husband should be ascertained. 
Men are averse to the confession of impotence, and will often 
allow the supposition of sterility on the part of their wives to 
be maintained rather than admit the truth. In two cases I have 
used an anaesthetic, ruptured the hymen, and distended the vagina, 
under the impression that sterility of several years' standing was 
due to the impossibility of the accomplishment of intercourse, and 
have subsequently discovered that the husbands of my patients 
were entirely impotent, and had been so before marriage. 

Prognosis. — In reference to a disorder which may be produced 
by such a variety of causes, no positive prognosis can be given, 
for its cure will depend in great degree upon the removal of the 
agency which produces it. Much, too, will depend upon the 
thorough investigation of the causes by the physician, and a 
proper understanding on his part, of the treatment. Unquestion- 
ably a large proportion of sterile women might, by appropriate 
treatment, be made fruitful. 



TREATMENT. 



497 



Results. — There are no 'physical results from sterility, but its 
existence will frequently depress the spirits and sadden a disposi- 
tion which, under other circumstances, would have been cheerful 
and equable. The married woman has always regarded and will 
forever view this incapacity as a reproach to her womanhood, and 
no amount of argument can make her accept it with resignation. 

Treatment. — The treatment of sterility consists in the removal 
of its causes. Many of these are not susceptible of remedy, while 
the means of treating others are so evident that special mention 
may be confined to a few. Obturator hymen, vaginismus, atresia 
vaginas, and occlusion of the cervical canal should be treated by 
the surgical operations appropriate to each. 

In case the vaginal cervix should, to only a limited extent, be 
too projecting or conical, the bilateral operation for its enlarge- 
ment should be practised after the method 
advised by Prof. Simpson for dysmenor- 
rhea. If a slight constriction of the cervi- 
cal canal appears to be the cause of the con- 
dition, dilatation by tents may be essayed 
in place of a surgical procedure. In an 
aggravated case, when the neck projects 
markedly and is decidedly conoidal in 
shape, both these means are insufficient ; am- 
putation then becomes necessary. The dia- 
gram (Fig. 198) shows the manner in which 
this should be performed. After this has 
been recovered from, the bilateral operation 
for cervical hysterotomy is often necessary 
before cure is effected. In this connection 
the chapters upon dysmenorrhea and ampu- 
tation of the cervix should be referred to. 

Metritis and endometritis, whether of body or cervix, should 
be appropriately treated, and abnormal growths should be dealt 
with as they should be if sterility did not exist. 

If a displacement be discovered and replacement and retention 
be possible, they should be practised. But if in case of flexion 
this be impossible, the uterine canal should be rendered as straight 
as is practicable, by the posterior cervical incision recommended 
by Dr. Sims for dysmenorrhoea. 
32 




The dotted lines show the 
excess of tissue in the cer- 
vix. (Sims.) 



Menorrhagia should be treated 



498 STEEILITY. 

upon the plan recommended in the chapter upon that subject, and 
the patient advised to remain very quiet and avoid warm and 
stimulating beverages during menstrual epochs. 

A remark made in connection with the treatment of leucorrhoea 
may, with propriety, be repeated here, namely, that to enter more 
minutely into the study of special remedial measures would tend 
to divert the mind of the reader from a point which I regard as 
of paramount importance, that this affection is only a symptom 
which should be reached through the malady which induces it. 



CHAPTER XL. 

AMPUTATION OF THE NECK OF THE UTERUS. 

Under certain circumstances where it is impossible to overcome 
morbid conditions of the cervix uteri by caustic and alterative 
applications, amputation of this part is practised. As a descrip- 
tion of the operation has not been called forth by any division of 
our subject which has thus far been treated, it will be well to 
allot a place to it here before leaving the consideration of uterine 
and taking up that of ovarian diseases. 

History. — Ambrose Pare 1 was the first surgeon who advised am- 
putation of the cervix. He recommended it in malignant growths 
of the part, to which, he says, "we may apply the speculum matri- 
cis, in order to see more easily." It is reported, upon insufficient 
authority, to have been performed as early as 1652 by Tulpius, 
of Amsterdam, and in 1766 by La Peyronie. Daniel Turner, 2 of 
London, in 1736, reported an instance in which the neck of a 
prolapsed uterus was amputated by means of a razor in the hands 
of the patient herself, who was insane. The recovery of the 
woman was evidently regarded as a wonderful circumstance. In 
1802 the operation was systematized by Osiander, who per- 
formed it twenty- three times, and after this it was resorted to by 
Dupuytren, Recamier, Hervez de Chegoin, and others. It was, 
however, in the hands of Lisfranc that it attracted special atten- 
tion, and, in consequence of his enthusiasm, it was for a time 
regarded as a means which was destined to accomplish a vast 
deal of good. His reports of its results were most flattering and 
he described its dangers as slight. But soon after his publications 
upon it there appeared a counter-report from the young physician 3 

1 CEuvres d'Ambroise Pare, lib. xxiv. p. 1012. 

2 N. Y. Med. Journ., vol. v. No. 5. 

3 Pauly, Maladies de 1' Uterus, Paris, 1S3G. 



500 AMPUTATION OF THE NECK OF THE UTERUS. 

who took charge of many of his cases and was familiar with all, 
which cast discredit upon all the master's statements. By Pauly, 
the truth was, as Becquerel expresses it, " brutally revealed," and 
was entirely at variance with the representations of Lisfranc. 
Since that time the operation has to a great degree fallen into 
disrepute, but is still resorted to in appropriate cases, and has 
now as advocates Simpson, Huguier, Sims, and others of equal 
eminence. 

Bangers. — The dangers of the procedure are as follows : — 
Primary hemorrhage ; 
Secondary hemorrhage ; 
Peritonitis ; 
Cellulitis. 
The statistics of the operation have not as yet been carefully 
collected. Lisfranc reported 99 operations and only two deaths, 
but these statements Pauly renders more than doubtful. Huguier 
reports 13 operations and no deaths ; Sims over 50 operations 
and one death ; and Simpson 8 operations and one death. 

Conditions Demanding Amputation. — The conditions which 
usually demand the operation are the following : — 
Cancroid tumor of the cervix ; 
Epithelial cancer of the cervix ; 
Cancer strictly localized ; 
Great induration from cervical metritis ; 
Longitudinal cervical hypertrophy; 
Conical and projecting cervix. 
One of these conditions, longitudinal cervical hypertrophy, not 
having previously received special mention, requires it here. The 
cervix may be congenitally very much elongated, either above or 
below the vaginal junction. Generally it undergoes hypertrophic 
elongation from a low grade of cervical metritis or endometritis, 
congestion long kept up, or prolapsus in the third degree. Under 
these circumstances the neck grows very long, so as to rest between 
the labia or even to project for a number of inches from the body, 
and has, in some instances, been mistaken for the penis. By 
means of the touch, conjoined manipulation, the speculum, and 
the probe, a diagnosis can readily be made. It was this con- 
dition which M. Huguier, some years ago, maintained, deceived 
practitioners into the belief in prolapsus uteri. 



OPERATION BY BISTOURY OR SCISSORS, 



501 



Varieties of the Operation. — In some cases, cancer, for example, 
it is necessary to remove the entire cervix and even as mnch tis- 
sue as possible from that portion of the organ above the vaginal 
attachment. In others, only half of the vaginal portion requires 
ablation, while in still another set of cases, only a thin section of 
the hypertrophied lips is called for. 

Methods of Performance. — The operation may be performed by 
the following methods : — 

By the bistoury or scissors ; 

By the ecraseur ; 

By the galvano-caustic. 
Operation by Bistoury or Scissors. — When performed by the first 
method, the patient sho aid be placed upon the left side and Sims's 
speculum employed. The cervix being slit bilaterally, one lip is 
seized and cut off as near the vaginal junction as is deemed advisa- 
ble, and then the other is removed in a similar manner. Formerly 
the operation was completed at this point, but Dr. Sims has in- 
troduced the practice of drawing down the mucous membrane and 
stitching it, as shown in Fig. 199, with silver sutures so as to 

Fig. 199. 




Covering stump of cervix with mucous membrane. (Sims.) 



cover the stump, as that of the arm or thigh is covered by skin 
after amputation of those parts. The scissors most advantageous 
for the purpose, will be found to be those bent at a right angle, as 
represented in Fig. 200. 



502 AMPUTATION OF THE NECK OF THE UTERUS. 

When the stump is covered by mucous membrane, after the 
plan of Sims, recovery is much more rapid than when granula- 
tion is allowed to accomplish the cure. 

Fig. 200. 




Uterine scissors, bent nearly at a right angle. 

Operation by the Ecraseur. — If the uterus be prolapsed, or if the 
degree of longitudinal hypertrophy be so excessive as to cause 
full protrusion of the cervix, or if such protrusion be attainable 
by moderate traction, the patient may be placed on the back. If 
the uterus be high up in the pelvis and strong traction be neces- 
sary to depress it, the best position will be found to be that ad- 
vised when scissors or the bistoury are employed, the speculum 
being used. The passage of the chain will be found to be very 
simple, and the part should be slowly cut through. 

In using the ecraseur for this purpose, great care should be 
observed not to allow of too great dragging of the chain upon 
the neck without cutting. If attention is not given to this point, 
the peritoneum may be opened. 

Operation by the Galvano- Caustic. — The galvano-caustic consists 
simply of an instrument which enables the operator to engage 
any part in a loop of wire which, being connected with a battery 
(Grennett's is that employed here), becomes white hot and cuts its 
way through. For the description which follows, as well as for 
the diagrams which accompany it, I am indebted to the kindness 
of Dr. B. F. Dawson, of this city. Figs. 201 and 202, represent 
the instrument. 

The patient having been put under the influence of chloroform 
or ether, is placed in a position similar to that for the operation 
of perineal section ; a sound is then introduced into the bladder 
in order to ascertain the extent of co-existing cystocele, and to 
reveal the exact limits of the bladder. Then the anterior lip of 
the cervix is transfixed by a long needle, immediately below the 
limits of the bladder, the point of the needle being directed 
somewhat obliquely, so as to penetrate into the cervical canal a 
few lines above its point of entrance. The finger of the left hand 



OPERATION BY THE GAL VANO- CAUSTIC. 503 

Fig. 201. Fig- 202. 




Fig. 201. — Galvano-caustic apparatus, b b, wire loop, a a, canulce. a, screw to fasten 
the canulae in place, b, canulse through which the wire passes, c, metallic supports. <L 
ivory screw around which the wire is wound to diminish the loop. E, brake to ivory 
screw. F, wire forming the loop. G, springs for connecting the supports and oanulse 
with the battery current. H, thumb slide to connect or break current. K, bone handle 
through which passes the connecting wires, L L. 

The wire loop is connected with the battery by passing through two metallic canuhv. 
which are inserted in the cross-pieces and fastened in place by the screws a. A bone 
handle enables the operator to hold the instrument without interfering with the current, 
and by means of the thumb slide IT, he may connect or disconnect the wire with the 
battery. 

Fig. 202. — Side view of the galvano-caustic apparatus. 



504 AMPUTATION OF THE NECK OF THE UTERUS. 

being introduced into the rectum to ascertain the degree of recto- 
cele present, the needle is then passed through the posterior lip in 
an opposite direction to its line of entrance, and as near as possi- 
ble to the limits of the rectocele. After the cervix is thus trans- 
fixed, it is seized by a pair of Muzeux's forceps, and the wire 
loop of the machine is then passed around it, immediately in 
front of the transfixing needle, and moderately tightened. Before 
connecting the wire loop with the battery it is advisable to re- 
move the needle, as it is likely to become heated if brought in 
contact with the loop. The current being turned on, and the 
wire loop becoming heated, the operator with his right hand 
slowly tightens the wire by turning an ivory screw, until the 
tissues are completely divided. The effect of the heat upon the 
divided tissues, differs according to its intensity; if the wire 
becomes heated to whiteness, there is scarcely any effect upon 
the tissue, for the parts being in consequence so much more 
quickly divided the heat has not time to radiate, whilst, if the 
wire is only red hot, an eschar is formed from one to three lines 
in thickness, in consequence of the coagulation of the albumen 
of the tissue. After the operation the prolapsed parts are pushed 
back into the pelvis, and the patient kept quiet in the recumbent 
position for six or seven days. Yaginal injections of water, or 
water and a small quantity of carbolic acid, is the only local 
treatment applied. There being no hemorrhage, styptics are un- 
necessary. The appearance of the divided surface is like that 
of a raw potato cut with a dull, rough, and slightly rusty knife. 

Operations by Drs. J. Kammerer and Guleke, at the German 
Dispensary. 

Case 1. Catherine D., aged 43, German, fourteen years mar- 
ried. Has had five children, the last one two years previous to 
operation ; prolapsus had existed since her fourth delivery. The 
vagina was wholly everted ; there was considerable cystocele and 
rectocele ; uterine cavity measured over five inches ; operated on 
the 8th of April; on the 16th was allowed to walk about; left 
the dispensary on the 25th ; examination May 18th ; uterine 
cavity measured three inches ; uterus in normal position ; cysto- 
cele entirely gone ; anterior wall of the vagina tense ; posterior 
wall somewhat relaxed ; slight rectocele still existing. 



OPERATIONS AT THE GERMAN DISPENSARY. 505 

Case 2. Amelia S., aged 40, German, fifteen years married. 
Has had four children, the last one two years previous to ope- 
ration. There was eversion of the vagina, cystocele, and recto- 
cele ; uterine cavity measured five inches ; operated on, on the 
17th of May ; four weeks after the operation the uterus was retro- 
flexed ; there was no prolapsus or rectocele, but a slight cystocele 
still remained. 



CHAPTEE XLI 



DISEASES OF THE OVAEIES. 



History. — Ancient literature is singularly barren upon the sub- 
ject of ovarian diseases. That the functions of these organs 
were known to early anatomists, there is no doubt — for as early 
as 200 B. C. the operation of castration of female animals is 
alluded to by Aristotle, and in the second century A. C. they 
were described by Galen under the name of " testes muliebres." 
As to the influence exerted by them upon menstruation, they 
were not informed — for they attributed that process, according 
to Aristotle, to a superfluity in the blood, an opinion which was 
entertained even by Hippocrates. The works of Ae'tius make no 
mention whatever of ovarian disorders, and those of Paul of 
iEgina are equally silent. When it is borne in mind that the 
ovular theory of menstruation dates back for its origin to the 
labors of Negrier, Gendrin, Lee, Bischoff, Pouchet, and others 
of our own time, and that the operation of ovariotomy was 
never systematically performed before the year 1809, it will be 
appreciated how recently the profession even in modern times 
has fully grappled with the subject. 

During the past ten or fifteen years full amends have been 
made for this delay, for since that time no portion of the field of 
Gynecology has received more attention or been more thoroughly 
elucidated than that which now engages us. Not only have 
most of the diseased conditions of the ovaries been satisfactorily 
investigated, and the diagnosis of them reduced to a scientific 
sj^stem ; for the most frequent and important, surgical means have 
been instituted with such success as to have given procedures of 
the most appalling character and undoubted dangers, the posi- 
tions of legitimate and justifiable operations. The recent litera- 
ture of ovarian pathology and surgery is now enriched by the 



ANATOMY OF THE OVARIES. 507 

contributions of so many capable observers, that it is almost 
invidious to particularize the most prominent. It may be stated, 
however, that Tilt, Wells, Clay, and Farre, in England ; Negrier, 
Pouchet, Coste, and Aran, in France; Scanzoni, Kiwisch, and 
Eokitansky, in Germany ; and McDowell, Atlee, and Peaslee, in 
America, are those to whose labors we are most indebted. Un- 
fortunately there is one set of ovarian affections with reference 
to which these statements are not true — those of inflammatory 
character. Our means of diagnosis of ovaritis, both acute and 
chronic, is, in spite of all the labors alluded to, so elementary and 
unreliable that the result is discordance of views and uncertainty 
as to pathology and therapeutics. It is probably the recollection 
of this fact which has led Scanzoni to open his article upon dis- 
eases of the ovaries with the following sentence. " If we felici- 
tate ourselves upon the progress which has been made during the 
last few years, in the diagnosis and treatment of the diseases of 
the uterus, we should, on the other hand, remember that the 
labors of gynecologists in respect to the diseases of the ovaries 
have been almost fruitless in practical results." 

Anatomy of the Ovaries. — The ovaries are two follicular glands 
about the shape and size of small almonds, situated one on each 
side of the uterus. So dependent are they upon the position of 
the uterus and surrounding viscera that they have really no fixed 
place. They are usually found in the lateral and posterior part 
of the true pelvis, about an inch from the uterus, and just below 
the point where the Fallopian tubes enter that organ, the left 
being in close proximity with the rectum. Bach ovary is covered 
over by peritoneum, which connects it with adjacent structures, 
and is firmly united with the uterus by means of a fibrous cord 
arising from the horn of each side. 

The Fallopian tube of each side is connected with the ovary by 
one fimbria, and acts at periods of ovulation as an excretory duct. 
Except at its attached margin the ovary is invested by peritoneum, 
beneath which is its own proper tunic of fibrous tissue called the 
tunica albuginea. Within this is a peculiar, soft, fibrous tissue or 
stroma of very vascular character, which contains a number of 
small, round, transparent vesicles called Graafian follicles. By 
the naked eye from ten to twenty of these are discernible, but by 
the aid of the microscope an immense number is seen. Removed 



508 DISEASES OF THE OVAEIES. 

from the stroma and examined with care by the microscope, each 
one of these vesicles is found to consist of a sac, called the tunic, 
which is filled with fluid, the liquor folliculi, in which is contained 
the ovum or egg, which is the female contribution to conception. 

It is now an accepted fact with most physiologists, although 
still contested by some, that the periodical discharge of blood 
from the uterus, which is called menstruation, is merely a uterine 
symptom of the discharge of one of the ova from the ovary by 
rupture of a follicle. After the period of puberty has arrived, one 
or more of the follicles of each ovary burst every month by the 
following process : a congestion or hypersemia occurring in the 
ovary for some reason beyond our comprehension, creates an 
excess of secretion from the walls of the follicle, in which a 
miniature dropsy takes place. This goes on to rupture, and 
escape of the liquor folliculi, blood, granular cells lining the ovi- 
sac, and the ovum. The nervous supply to both uterus and 
ovaries is excited by this, and one of the results of such excite- 
ment is a rupture of the bloodvessels of the mucous membrane 
of the uterus and escape of blood. The ovisac being emptied, a 
clot of blood soon forms within it, then an hypertrophy of the 
cells lining it occurs, and the corpus luteum is formed. 

If the examiner hold up one of the broad ligaments between 
himself and the light, a small plexus of white, crooked tubes will 
be seen forming a cone, the apex of which is directed towards the 
hilus of the ovary. It measures about an inch in breadth, and 
consists of about twenty tubes which are filled with a clear fluid. 
This is the organ of Eosenmuller, which has recently been 
minutely described by Kobelt under the name of the par-ovarium, 
and is supposed by him to be an exaggeration of the Wolffian 
body. The exact location of the par-ovaria is this: they lie be- 
neath the ovaries and between the ultimate folds of the perito- 
neum covering the fimbriated extremities of the Fallopian tubes, 
which have received the name of the alae vespertilionum. 

The ovaries are supplied with blood through the spermatic 
arteries, which, upon arriving at the margin of the pelvis, pass 
inwards between the layers of the broad ligaments, and thus reach 
their lower border. Their nervous supply is not extensive, and is 
derived from the renal plexus. 

Varieties of Ovarian Disease. — Any one or all the tissues just 






IMPEKFECT DEVELOPMENT. 509 

described may be affected by disease, or the position of the ovary 
may be altered to such an extent as to constitute a disease. The 
following presents a list of the disorders of these glands which 
Will now receive special attention : — 

Imperfect development ; 

Atrophy ; 

Hypertrophy ; 

Apoplexy ; 

Inflammation ; 

Tumors. 

IMPEEFECT DEVELOPMENT. 

The ovaries may be congenitally absent, or the foetal state may 
remain after the period of puberty when rapid development should 
have occurred. 

Absence of the Ovaries. — One or both of these organs may be 
absent, but such a condition is very rare. When it does occur, it 
is generally only a part of a complete want of genital develop- 
ment which is manifested not only by these organs but by the 
parts making up the vulva, the vagina, and the uterus. Kiwisch 
declares that it has been most frequently observed in the bodies 
of newly-born infants who were not viable on account of compli- 
cated deformities. 

When the ovaries are removed from a fully matured woman 
her whole aspect changes. The breasts become flat, the features 
and voice masculine, and beard appears upon the face ; or rather, 
such have been the results in the few instances in which the ex- 
periment has been tried, as, for example, in the celebrated case 
in which Percival Pott extirpated both ovaries which were lodged 
in the inguinal canals. But where there, is a congenital absence, 
such is not the case; the woman is generally small in stature, her 
figure undeveloped, as if the period of girlhood were abnormally 
prolonged, and the genital system imperfect, as already mentioned. 

Although a certain diagnosis can only be arrived at post-mor- 
tem, a legitimate deduction may be drawn during life which may 
guide us in prognosis and treatment. Indeed, one of the greatest 
benefits which can accrue from a correct conclusion will consist 
in the avoidance of all efforts which, being vainly addressed to 
exciting the function of the ovaries, depreciate the state of the 



510 DISEASES OF THE OVARIES. 

patient. Should the general condition of the patient, the unde- 
veloped state of the vulva, vagina, and uterus, and the entire 
absence of the menstrual crisis combine as evidences of the con- 
dition, a diagnosis is admissible. 

Undeveloped Ovaries. — This condition, which consists in persist- 
ence of the foetal condition of these organs, is by no means so 
rare as that just mentioned. It may exist on one side only, though 
it generally affects both. As in the case of absence, a certain con- 
clusion is not easy, and as in that case, also, we draw a presumptive 
conclusion from want of development in the other organs of gene- 
ration, absence of the usual signs of the menstrual crisis, and lack 
of general constitutional vigor and development. 

As examples of cases susceptible of such an explanation I 
record the histories of two with which I have recently met. 
The first is that of Miss F., referred to me by Dr. Eodenstein, of 
Manhattan ville. She is twenty- four years of age, and yet has the 
appearance of a girl of thirteen. Indeed, it is difficult to believe 
the statement that she is more than that age. The features, limbs, 
mode of expression, and general deportment are those of a child. 
She has never menstruated or shown any evidences of a tendency 
to do so. Physical exploration shows the vulva in the state of 
early girlhood, the mons veneris uncovered by hair, the labia 
thin, and the vagina so small and narrow that the little finger 
only can be introduced, and that causes great suffering. The 
canal being short as well as narrow, the uterus can be touched, 
and is found like a little nut in the vagina, so light that its weight 
is scarcely perceptible. 

The second case is one which I occasionally see with Prof. W. 
H. Thompson. The patient is eighteen years old, and has never 
menstruated. Previous to the treatment established by Dr. 
Thompson, she suffered greatly from epileptic seizures, which 
have evidently impaired the force of her intellect, but during the 
past two months she has been free from them. 

The girl is slow in her movements, childish in manner, and 
stupid in replying to questions. Upon physical exploration, the 
vulva, vagina, and uterus are found fully and perfectly developed, 
the latter giving by measurement with the uterine probe, two and a 
half inches. Nothing can be elicited with reference to the ovaries 
by physical means, but the rational signs mentioned, together with 



IMPEEFECT DEVELOPMENT. 511 

the fact that all the appearances of girlhood are combined with 
entire absence of any apparent effort at ovulation, render the 
supposition that the ovaries are undeveloped or foetal highly 
probable. 

Sometimes cases will be met with in which masculine develop- 
ment, emansio-mensium, and sterility will lead to a diagnosis of 
absence of the ovaries, but which will subsequently undergo a 
change and give all the evidences of the presence and efficiency 
of these organs. One such case, which occurred in the practice 
of Dr. Metcalfe and myself, is worthy of record. Mrs. B., a large, 
muscular, and handsome woman, had menstruated very irregularly 
and scantily for ten or fifteen years. Sometimes the menstrual 
discharge would be entirely absent for months, then it would at 
long and irregular intervals show itself for a day. Her health 
was not affected by this in any way. She presented, however, 
many signs of masculinity ; the voice was harsh, the breasts 
flat, and the chin covered with a sparse beard. After having been 
married for years she became pregnant, and in due time bore a 
child, subsequent to which she menstruated more regularly and 
plentifully, and has since borne two children. 

Treatment. — Should the ovaries be congenitally absent, it is 
evident that art can do nothing to remedy the evil. Should they 
exist in an undeveloped or foetal state, it is highly probable that 
by a proper stimulus applied to them by the most direct means 
in our power, growth and maturity may be fostered, unless the 
condition be one of aggravated arrest of development. The 
means which are most likely to accomplish this are : — 

General tonics ; 

Uterine irritation ; 

Electricity ; 

Marriage. 
The sanguineous and nervous systems should both be brought 
into as "perfect a state of health as possible by ferruginous and 
bitter tonics, fresh air, exercise, change of scene, and a general 
observance of the laws of hygiene. 

The most direct method for irritating the ovaries is through the 
uterus, with which so keen a sympathy exists. For this purpose 
tents may be occasionally resorted to, as often, for instance, as 
once or twice a fortnight or month. This not only prepares the 



512 DISEASES OF THE OVARIES. 

uterus for its part of the process, menstruation, but causes a hy- 
peremia in the ovaries, which we know to be the physiological 
forerunner of ovulation. 

Electricity may be employed by placing one pole of a battery 
over the spine and one over the ovaries, or, better still, by carry- 
ing one pole, protected where it touches the vagina, to the cervix 
uteri, connecting this with a battery and passing the other pole 
over the ovaries. An intra-uterine galvanic pessary may like- 
wise answer a good purpose. 

The ovarian irritation and congestion incident to the marital 
act will sometimes excite ovulation, not at the moment of coition 
as was formerly supposed, but remotely. 

Atrophy of the Ovaries. — At a period, varying from the fortieth 
to the forty-fifth year, the ovaries are destined to undergo atrophy. 
They diminish in volume, become wrinkled, the Graafian folli- 
cles disappear, and the stroma becomes dense and non- vascular. 
This is a physiological process, and marks what is termed the 
menopause, or period of menstrual cessation. Sometimes this pro- 
cess sets in at a very early period, owing to some abnormal con- 
dition which has excited it, and produces the same results as those 
following it at the normal time. 

Causes. — With regard to the special causes of this occurrence 
very little is absolutely known, further than the fact that it some- 
times occurs from pelvic inflammations. It is probable that 
acute ovaritis may produce it, and it is certain that it results from 
pelvic peritonitis and cellulitis. 

The following case which presented itself at my clinique a few 
weeks ago is illustrative of this fact. Mary G., a healthy young 
Irish woman, aged 24 years, stated that she had a miscarriage at 
the third menstrual period, five years ago in Albany. Three days 
.after the product of conception had been cast off, she was taken 
with a chill, violent pain over the abdomen, and was declared by 
her physician to have inflammation of the bowels. Of this attack 
she nearly died, but after a confinement to bed for six weeks grew 
better. For two years after this she had irregular, painful, and 
profuse menstruation. As she expressed it, whenever she became 
fatigued or excited, flooding would come on. After this time the 
menstrual periods disappeared, and now she applies for relief on 
account of amenorrhcea of three years' standing. Physical ex- 



HYPERTROPHY OF THE OVARIES. 513 

ploration revealed the uterus in normal condition, though dimin- 
ished in size to about two inches. Nothing could be ascertained 
about the ovaries. 

The view which I took of the' case was that pelvic peritonitis and 
acute ovaritis originally existed. These left the parts in such a 
state that for two years metrorrhagia and menorrhagia occurred. 
Then subsequent contraction occurring in the effused lymph in 
and around the ovaries, atrophy resulted with its usual conse- 
quence, amenorrhoea. 

The peculiarly destructive influence exerted upon the ovaries 
by pelvic peritonitis will be impressed upon any one who makes 
an autopsy in a patient who has died of that affection, or who 
reads the reports of others. Yery often the ovaries cannot be 
discovered in the mass of "putrilage" which occupies their site. 

Treatment. — An attempt may be made, by the means recom- 
mended in the treatment of undeveloped ovaries, to excite ovula- 
tion in any part of the glands which may be still capable of per- 
forming the function. But it should not be persisted in if not 
at once attended by good results, for inflammatory action may 
be excited by it. When these means are essayed, great caution 
should be observed and their influence developed only to a limited 
degree. 

HYPERTROPHY OF THE OVARIES. 

When from prolonged congestion, or a low grade of inflamma- 
tion which does not go on to the production of suppuration, the 
nutrition of the ovarian tissues is kept up to a maximum degree, 
these organs undergo enlargement from increase in the amount 
of their parenchyma, and hypertrophy is said to exist. Kiwisch 
declares that under these circumstances complete atrophy of the 
follicles always occurs, and thus ovaries which appear exces- 
sively developed may evidence the same functional disability as 
those which are entirely atrophied. There is a marked difference 
between this state and that enlargement which results from mere 
effusion of lymph, a consequence of inflammatory engorgement. 
The latter is merely one of the stages of inflammation. But if 
the material thus effused, becoming organized, is appropriated, as 
it were, by the organ in which it exists, as one of its component 
parts, then the case belongs to the former category. Although, 
33 



514 DISEASES OF THE OVAEIES. 

then, hypertrophy is not an immediate, it may be a remote result 
of inflammation, as has been pointed out by Kiwisch. Kokitan- 
sky disposes of the subject in a few words, merely stating that 
this condition may be one of the results of hyperemia, and Wedl 
makes no allusion to it. 

Dr. Bright describes an instance of this affection in which the 
ovaries were as large as kidneys, and of solid, fleshy consistence, 
unlike malignant disease. The symptoms attending this case are 
given below. 

The symptoms of ovarian hypertrophy are very obscure, 
and very little is known concerning the clinical history of the 
affection. A sense of weight in the iliac regions and groins, dis- 
comfort upon locomotion, and disorders of menstruation may be 
assumed to be symptomatic of its existence as far as rational signs 
are concerned. To go further than this would be risking the 
admission of mere theory, where only clinical facts should have 
weight. The following is the history of Dr. Bright's case. "The 
woman had borne children, and when past the menstrual period 
of life, was seized with pains which were referred to the uterus. 
These continued more or less acute for two months, when a con- 
siderable, indurated substance was perceptible in the regio pubis, 
referable, as was considered, to a morbid state of the uterus. 
After this time a difficulty in making water added greatly to her 
suffering ; indeed it amounted to inability in the erect position 
of the body, but the recumbent posture sensibly removed the 
only impediment to its discharge. From anxiety, which her 
intolerable pain induced, or from a combination of circumstances, 
she became the most emaciated object I ever witnessed. Jaun- 
dice supervened, attended with ascites, and in this precarious 
situation, some one being consulted, took up the idea of its being 
a scirrhous liver, and recommended a moderate ptyalism to be 
raised and supported. The hardened substance before mentioned 
was considered by him as a continuation of the liver. Mercury, 
however, was only given in small quantities ; and soon after she 
began its use, death closed the scene." 

This history is given for what it is worth. It is certainly a 
remarkable one, supposing that Dr. Bright was correct in regard- 
ing the disease as being non-malignant; but it cannot be looked 



OVARIAN APOPLEXY. 515 

upon as typical of the course of an affection, the prognosis of 
which is by no means unfavorable. 

As the rational signs of hypertrophy are so meagre, it is fortu- 
nate that those which are physical are much more reliable. The 
increase of size and weight dependent upon the disease, very 
often displaces the ovary, when it is discovered by conjoined mani- 
pulation as a slightly sensitive body, usually about the size of a 
walnut, in Douglas's cul-de-sac, or by the side of the uterus. 
Even if the ovary or ovaries affected keep their normal position, 
careful manipulation will, unless the patient be very fat, discover 
their enlargement. Should they be fully within reach of investi- 
gation by touch, and doubt exist as to the nature of the tumor 
felt, the facts of their becoming very turgid and sensitive during 
menstrual epochs, and diminishing in size and sensibility after 
these periods have passed, will serve to settle the question. 

Treatment. — An attempt should be made to stimulate absorp- 
tion by the persevering use of iodine, in the form of tincture or 
ointment, over the hypogastrium and over the whole surface of 
the vagina, where it may be painted through the speculum ; and 
irrigation per vaginam by warm water holding in solution iodine, 
chloride of sodium, or iodide of potassium. The use of the iodides 
internally, of sea bathing, and of mineral waters internally and 
externally, and observance of quietude during menstrual periods, 
when congestion adds itself to the existing disease, also constitute 
useful measures. 

ovarian apoplexy: 

Definition. — The word apoplexy is very loosely employed in refe- 
rence to sanguineous effusions in all the organs of the body, some 
signifying by it sudden vascular rupture, while others apply it to 
interstitial hemorrhage occurring even very slowly. This has 
created confusion of description, and certainly added difficulty to 
the clear comprehension of the pathological states to which it has 
been synonymously applied. Thus, in describing ovarian apo- 
plexy, Kiwisch 1 divides it into primary and secondary, consider- 
ing as examples of the latter hemorrhage from the walls of a 
cyst which fills it slowly with blood, or hemorrhage the result of 
tapping. The two conditions should be regarded as essentially 

1 Op. oit., p. 232. 



516 DISEASES OF THE OVARIES. 

different, and I would offer this as the proper definition of our 
subject. Apoplexy of the ovary consists in a rapid effusion into 
its tissue of blood which results from sudden rupture of one or 
more of its larger vessels. 

The ovaries present the only example in the economy, of apo- 
plexy occurring as a physiological act. . At each menstrual 
period, as an ovule leaves its nidus, ah apoplexy from the vessels 
of the tunic of the pvisac occurs as a necessary consequence. It 
is this which, upon subsequent alteration, constitutes the corpus 
luteum. Generally these hemorrhages are self-limiting, and their 
effects rapidly disappear ; in some cases, however, the bleeding 
continues longer or returns, and then the collection of blood 
sometimes reaches the size of a fist or of a child's head. 1 In 
some instances the tunica albuginea of the ovary is completely 
ruptured, when the effused blood pours into the most dependent 
portion of the pelvic cavity, constituting pelvic hematocele. 

Symptoms. — The occurrence of apoplexy is often ascertained 
only in autopsy ; no signs existing during life by which it can 
be positively diagnosticated. Those symptoms which will usu- 
ally point to its existence, are sudden and violent pain over 
the region of one ovary, with sense of great exhaustion, nausea, 
and vomiting. These symptoms, if combined with enlargement 
and tenderness of one ovary, as ascertained by conjoined manipu- 
lation, will be sufficient to render a diagnosis warrantable if the 
patient's health has been previously good. 

Prognosis. — The great danger from the accident is peritonitis, 
arising either from implication of the visceral layer as it covers 
the ovary, or from rupture of the tunica albuginea and occurrence 
of hematocele. 

Treatment. — Should there be symptoms of peritonitis, leeches 
should be applied, and followed by poultices or a blister. Beyond 
this, all that can be done is to keep the patient quiet in the recum- 
bent posture, and avoid all muscular effort until absorption occurs. 

DISLOCATION OF THE OVARIES. 

The extreme mobility of these glands and the laxity of their 
supports have already been remarked upon. Any influence 

1 Kiwisch, op. cit., p. 232. 



OVARITIS. 517 

■which increases their weight, draws upon them directly, or acts 
upon them by traction upon a neighboring organ, may cause 
them to leave their position, and even in rare cases to pass out of 
the pelvis in the form of hernia. In the first method they may be 
displaced by inflammation, hypertrophy, ovarian foetation, &o. 
In the second they may be acted upon by contractions of effused 
lymph, resulting from pelvic peritonitis, contraction of the ovarian 
ligament, &c. In the third they may be affected by displacement 
of the uterus, pregnancy, or hernia of any of the abdominal vis- 
cera. A hernia of the ovary alone is very rare ; it is almost 
always attended by hernia of the Fallopian tube, or some portion 
of the intestines or omentum. 

The ovaries often fall when their weight is increased, into the 
cul-de-sac of Douglas. More rarely they pass into the inguinal 
canals, or through them into the dartoid sacs of the labia majora. 
Here they show a monthly intumescence which creates great local 
disturbance and keeps the parts swollen, heated, and tender until 
ovulation is passed. Deneux 1 declares that they may enter the 
femoral, umbilical, and ischiatic openings, or form a part of ven- 
tral hernia, and Kiwisch has reported a case in which one entered 
the foramen ovale. The accident is rarely important in its results, 
except in reference to excluding the suspicion of other forms of 
tumor and avoiding the danger of surgical interference under a 
mistaken diagnosis. 

Treatment. — The treatment consists in returning the dislocated 
part by taxis, and keeping it in situ by a properly constructed 
truss, pessary, Qr bandage. Should the displaced gland be bound 
in its false position by strong membranes, the propriety of its 
removal might be considered, in case serious inconvenience re- 
sulted from the dislocation. 

OVARITIS. 

Definition. — By this term is meant an inflammation of the 
tissue comprising the ovaries, which has been described by some 
authors under the name of Oophoritis. A dogmatic treatise upon 
ovaritis in the non-puerperal woman is in the present state of 
science impossible. So much concerning the disease is unsettled, 
and such utterly discordant views are entertained upon it by the 

1 Reolierches sur la Hernie de l'Ovaire. 



518 DISEASES OF THE OVAEIES. 

most reliable authorities, that too great caution cannot be observed 
in treating of the subject, lest theories constructed upon analogi- 
cal reasoning be made to pass current in the mind of the reader 
for facts faithfully observed at the bedside and in the dead-house. 
No writer should attempt its description without determining, as 
Aran did, when he penned the following sentence, " I leave out 
of consideration all the fantastic descriptions of ovaritis which 
have been constructed in the library by physicians who were more 
remarkable for brilliancy of imagination than knowledge of the 
disease." Our knowledge of the subject is at least so far ad- 
vanced as to make a thesis upon it entirely inadmissible. 

Varieties. — Ovaritis may be either puerperal or non-puerperal. 
The first does not concern our present investigation, and we put 
it out of consideration. The non-puerperal form of the disease 
has been divided into acute and chronic, which will in order now 
engage us. 

Acute Ovaritis. 

This affection, though very common as a result of parturition 
or abortion, is quite rare in the non-puerperal woman. Mme. 
Boivin' even goes so far as to say that "it would be difficult to 
point to a single well authenticated case out of the condition of 
pregnancy." Dr. West 2 remarks that " acute inflammation of the 
substance of the unimpregnated ovary is of such rare occurrence 
that no case has come under my own care, and but one has pre- 
sented itself to my observation." Prof. Fordyce Barker 3 says: 
"I doubt very much if I have ever seen a clear, well-marked 
case, and I have been for years looking for its existence in the 
dead-house." There can be no question of the truth of these 
statements as regards pure, uncomplicated inflammation of the 
ovary, but ovaritis of acute character going on to suppuration or 
production of a diffluent state of the stroma, is by no means rare 
as a complication of pelvic cellulitis or peritonitis. One of the 
greatest dangers to be feared from these diseases is injury or 
destruction of the ovaries, and it is probable that few cases of cel- 
lulitis and none of peritonitis run their course without involving 

1 Op. cit. 2 Op. cit.. p. 473. 

3 Bui. N. Y. Acad. Med., vol. i. p. 549. 



ACUTE OVARITIS. 519 

them to a greater or less extent. It is likewise probable that pel- 
vic peritonitis is frequently excited by some trouble originating in 
the ovaries, which are closely enveloped by peritoneum continuous 
with that making up the broad ligaments and covering the pelvic 
roof. The intimate relation of these three parts, the ovaries, the 
pelvic peritoneum, and the pelvic areolar tissue, accounts for the 
fact that uncomplicated acute ovaritis is rarely met with. 

In proof of this statement let me point to the condition of the 
ovaries in the autopsies of peri-uterine cellulitis reported by Aran. 
In almost all instances they were diseased and generally contained 
pus. So common was this lesion that Aran was persuaded that 
"the purulent collections which, as a consequence of peri-uterine 
inflammation, discharge themselves into the peritoneum or into 
the organs in the neighborhood of which they are placed, rectum, 
bladder, vagina, &c, sometimes even by the surface, belong more 
particularly to the ovary or tube." 

Authors have divided acute ovaritis into parenchymatous, fol- 
licular, and peritoneal, but in an affection, the mere recognition 
of which is so difficult, it is hardly Avise to refine upon its pecu- 
liarities. The form of the affection here styled peritoneal is really 
not ovaritis but peritonitis of the very character of which we are 
speaking ; from which to parenchymatous and follicular disease 
there is only one step. As an example of ovaritis thus compli- 
cated in a non-pregnant woman, I avail myself of the kindness of 
Dr. Eoth and record the following history prepared by him : — 

" M. S., set. 35, married ten years, had a miscarriage nine 
years ago. Since that time has suffered from dysmenorrhcea and 
gastric disorder, which was styled dyspepsia. Two years ago she 
applied to me, and I found her suffering from profuse fluor albus 
and retroflexion of the womb. Under use of caustics and tonics 
she improved very much, and treatment was stopped. I did not 
see her again until August 1st, 1866, when I found her in a con- 
vulsion. After it had passed off she vomited constantly, com- 
plained of great pain in the bowels, was very thirsty, and the 
pulse was near a hundred. Opium was freely administered. On 
the next day the pulse was over one hundred ; skin hot and dry ; 
and she complained of severe pain in back and loins, and over 
left iliac fossa. I made a vaginal examination by touch, but could 
discover nothing except that the vagina was very hot and dry. 



520 DISEASES OF THE OVARIES. 

Aug. 3. No great change, except that the abdomen became tym- 
panitic. Aug. 4. She lost about five ounces of blood per vaginam ; 
symptoms unchanged. Aug. 6. She was seen in consultation by 
Prof. Thomas, who diagnosticated pelvic peritonitis with probable 
acute ovaritis on left side, and anticipated formation of an abscess 
near or in the ovary. By his advice a large blister was applied 
over the hypogastrium, and opium given in very large doses. The 
case went on in this way until Aug. 11th, when she suddenly 
vomited a large amount of bile, became collapsed, and died that 
night. 

" Autopsy eighteen hours after death. — The peritoneum covering 
the pelvic viscera was covered with a recent lymph, and between 
the organs a great deal of puriform serum existed. Abdominal 
peritoneum healthy. The left ovary, which was agglutinated to 
the intestines, tubes, and uterus, was about the size of a hen's egg. 
In its removal it was broken, and several ounces of pure pus 
escaped. No evidences of cellulitis could be discovered upon 
careful dissection. Other organs healthy." 

The interest of the following case, for the history of which I am 
indebted to Dr. Jerome C. Smith, will warrant its introduction : — 

" M. A., aged eighteen, first menstruated at the age of thirteen 
years. Had not been in good health for a year previous, having 
every four weeks violent headache, flushed face, pain in back and 
abdomen continuing about twenty-four hours. Her physician 
ascribed it to the expected appearance of the catamenia, and pre- 
scribed a chalybeate. The catamenia appeared on an occasion of 
her receiving a very severe fright, and was profuse, lastiug about 
six days. This condition, with no inconvenience except slight 
pain in the back, occurred at each regular period for five months. 
At this time, while menstruating, she took a river bath of fresh 
water, which occasioned immediate suppression with violent pain. 
Domestic remedies used, produced a slight reappearance, but on 
all subsequent occasions the menses were very scanty, never last- 
ing more than four days, and accompanied with considerable 
pain. The character of the discharges was also altered. From 
this period there were irregularities, and at one time, a year 
later, complete suppression for four months. Dewees's tincture of 
guaiac was administered, and not proving efficacious, chalybeates 
were used with benefit. 



ACUTE OVAKITIS. 521 

" The patient menstruated July 4, 1865, which for the first time 
was a few days premature. July 22d, while on a visit in the 
country, she took a long walk, and then going in a small boat 
took the oar and rowed two miles, an exercise to which she was 
entirely unaccustomed. While rowing, the catamenia appeared — 
only eighteen days after her last period — and continued less than 
two days. The next appearance was August 16th, three days 
premature, and continued until the morning of the 17th, when 
there was a sudden suppression accompanied with violent pain. 
Warm drinks and brandy were administered, and the feet im- 
mersed in hot mustard water. Domestic remedies failing, the 
family physician was called and arrived in the evening. She 
then complained of an aching sensation in the limbs, and there 
was some fever. The physician ordered ice to be applied along 
the spinal ganglia, to be constantly renewed until the catamenia 
reappeared, and gave her some ' fever mixture.' After midnight, 
the patient feeling very uncomfortable and desiring to sleep, the 
ice was discontinued until the doctor's morning visit, when he 
ordered it to be reapplied for two hours and then taken off, allow- 
ing the patient to rest for two hours, and this course to be con- 
tinued till the flow should appear, with the addition, if there 
should be pain, of the application to the abdomen of cloths 
wrung out of hot water, during the two-hour intervals when the 
ice was not applied. This was done faithfully until the menses 
appeared very scantily, disappearing when the ice was discon- 
tinued, and reappearing again on another application, still scantily. 
Her physician regarded her then as requiring no other medical 
treatment further than a cathartic, and discharged the patient, 
directing that he should be sent for if she should not be as well 
the next day. The cathartic produced numerous evacuations 
during several successive hours. The following day, as she had 
considerable fever, the physician was sent for, and ordered 
quinine pills and renewed the fever mixture. When she com- 
plained of pain, the nurse put the feet in hot water, or applied 
hot cloths to the abdomen. 

" On Monday, the fifth day, she complained of considerable pain, 
and the doctor was again sent for ; and ordered every two hours 
pills containing opium gr. ss, pulv. ipecac, comp. gr. ij, which 
constipated the bowels. A cathartic was given, producing active 



522 DISEASES OF THE OVARIES. 

diarrhoea with tenesmus. The discharges soon became mucous 
and tenesmus increased, and pills containing hydrarg. chl. mitis 
gr. J, opii gr. ■§-, plumbi acetat. gr. iss, were ordered. The mucous 
discharges continued thereafter with some variation and great 
tenesmus. Oleum ricini, with tr. opii, was directed to be given 
in the evening. There was no tympanites. Pain and fever in- 
creased to an alarming extent. The castor oil and laudanum were 
given as ordered. At midnight the patient was seized with an 
agonizing pain in the abdomen, and immediately became slightly 
delirious. 

"From this time the countenance changed, the extremities grew 
cold, and could not be warmed, though vigorous means were 
resorted to by her nurse. In the morning the physician was 
astonished to find her moribund. He now, for the first time, 
discovered the serious nature of the disease. The most vigorous 
measures were unavailing. It may be here remarked that the 
patient was a very heroic girl, and did not manifest the amount of 
pain she suffered. She died at twelve o'clock on the tenth day 
of the disease. 

" Autopsy forty -eight hours after death. — The abdomen was 
opened and revealed agglutination of the intestines everywhere, 
with an effusion of several ounces of pus mixed to a greater or 
less extent with serum. An abundance of organized lymph lined 
the pelvic cavity and elsewhere. Eaising the right ovary in situ 
upon the finger a quantity of pus escaped from a rupture of that 
organ sufficient to flow over in every direction. When the uterus 
was removed with its appendages there was found to be a dilata- 
tion of the right Fallopian tube, at one point, as large as a man's 
thumb, filled with pus. The left ovary contained two corpora 
lutea in a recent state. Both Fallopian tubes were pervious. The 
uterus was healthy. The rectum contained a large quantity of 
mucus." 

Pathology. — This is not clearly made out, though it appears safe 
to accept the stages described by Mme. Boivin : First stage, con- 
gestion, with increase of weight and rotundity; second stage, size 
of organ double, triple, or quadruple the normal size, tissue soft 
and infiltrated with yellow and violet colored serum, with slight 
effusion of blood; third stage, suppuration, pus infiltrated or 



ACUTE OVARITIS. 523 

collected in spots ; fourth stage, gray softening, disorganization, 
the gland becoming difflnent. 

Causes. — The causes of the disease may be thus enumerated : — 

Pelvic peritonitis ; 

Peri-uterine cellulitis ; 

Gonorrhoea ; 

Disturbance of menstruation. 
Any of the causes which have been enumerated as sufficient to 
cause the two first diseases mentioned may through them produce 
ovaritis. A form of ovaritis called blennorrhagic is admitted by 
most authors as corresponding with blennorrhagic orchitis in the 
male. It is difficult to see how even the progress of gonorrhceal 
inflammation along the tubes would cause disease of an organ not 
connected with the extremity of these tubes. Let it be remem- 
bered that gonorrhoea is in this way one of the most fruitful 
sources of pelvic peritonitis, and an explanation of ovaritis as a 
secondary result will suggest itself. Suppression of menstruation, 
or any sudden and violent shock given to the ovaries while ovu- 
lation is progressing and the walls of the organ are about being 
broken through, may likewise induce it. 

Symptoms. — The symptoms of this affection are so intimately 
associated with those of peritonitis and cellulitis that it is impos- 
sible to separate them. There is severe pain in one or other iliac 
fossa, with increase of heat, fever, and perhaps chill. Pressure 
shows the most exquisite sensitiveness, and when the part is 
examined by conjoined manipulation this is excessive. By that 
means the ovary is felt enlarged and generally depressed in the 
pelvis. These symptoms may subside upon the occurrence of 
resolution in four or five days. Or pus forming within the gland 
may be discharged into the peritoneum, the rectum, the vagina, 
or the bladder. 

Differentiation. — This is generally impossible. The association 
of the disease with those which have been mentioned as being 
sometimes its causes, at others its consequences, is too intimate 
for its accomplishment. Should conjoined manipulation discover 
the ovary as a round ball, very sensitive, and unassociated with 
fixation of the uterus, a diagnosis would be admissible. T have 
never met with such a case, nor is it likely that they often occur. 



524 DISEASES OF THE OVAEIES. 

Prognosis. — The prognosis is favorable, though never free from 
an element of doubt. 

Treatment. — Leeches should be promptly applied around the 
anus, over the diseased organ, or at the groin. Should its weight 
not give pain, a poultice should then be placed over the hypogas- 
trium, and opium freely administered by mouth and rectum. The 
patient should be kept perfectly quiet, and not allowed to rise 
from her bed even for relief to the calls of nature. This should 
be especially attended to if it be supposed that suppuration has 
occurred, for then a very slight effort might cause a rupture of 
the abscess into the peritoneum. 

Chronic Ovaritis. 

That chronic inflammation may affect the ovaries there is no 
good reason for doubting, though very little has been ascertained as 
to the frequency of the affection. So great is the sympathy exist- 
ing between the uterus and these organs, that uterine disorders 
excite ovarian pain very commonly, and give rise to many symp- 
toms regarded by authors as characteristic of this disease. Again, 
it is a well ascertained fact that slight attacks of chronic pelvic 
peritonitis are extremely common, and unfortunately we possess 
no certain means for distinguishing such a disorder, in the vicinity 
of an ovary, from chronic ovaritis. 

In the great majority of cases of uterine disease the patient will 
complain of pain of dull, aching character over one or both ovaries, 
and this will very likely be augmented by menstruation. But it 
is by no means to be concluded that this sympathetic pain, even if 
dependent, as it very often is, upon congestion, is due to chronic 
ovaritis. As well might it be believed that mammary pains ex- 
cited in the same manner are due to mammitis. But it cannot 
be denied that we sometimes meet with cases of chronic ovaritis, 
which may be recognized by the following symptoms : — 

Symptoms. — Fixed pain without uterine disease ; 
Increase of this at menstruation ; 
Tenderness upon pressure ; 

Detection of an enlarged ovary by conjoined mani- 
pulation and rectal touch. 

These are the symptoms which warrant a belief in the existence 



OVARIAN ABSCESS. 525 

of the disease. In addition we may find, especially when the left 
ovary is affected, great prostration after an alvine evacnation, 
excessive weariness after exertion, disturbance of the nervous 
system amounting to hysteria, and depression of spirits. 

Prognosis. — The prognosis is always favorable, though cure is 
often difficult of accomplishment. 

Treatment. — Eest should be prescribed during menstrual epochs, 
when the diseased gland is congested and in a state of nervous 
excitement. Severe exercise, or fatiguing occupations should be 
avoided, and all influences calculated to depress the vital forces 
carefully guarded against. Counter-irritation by means of small 
blisters, tincture of iodine, or issues of nitric acid, should be kept 
up over the diseased organ for months at a time, and once or twice 
a week the cervix uteri and whole upper part of the vagina 
should be painted over with tincture of iodine. Every night and 
morning the patient should be directed to use copious injections 
of warm water into the vagina by means of a syringe with con- 
tinuous jet, like Davidson's or the Essex. For the various symp- 
toms which accompany the affection the bromide of potassium in 
scruple or half drachm doses will be found very beneficial. 

OVARIAN ABSCESS. 

One of the ordinary results of acute ovaritis is formation of 
pus. This may discharge itself rapidly, become encysted, or dis- 
charging after a length of time remain a pyogenic sac which fills, 
and empties itself at intervals. Kiwisch asserts that as a result 
of inflammation abscesses may originate either in the parenchyma 
or in one of the follicles of the gland, and that the non-puerperal 
form generally has the former and the puerperal the latter origin. 
In either case depots may be established which will contain an 
incredible amount of pus. Kiwisch has seen them contain as 
much as sixteen pounds, and Dr. Taylor, 1 of Philadelphia, reports 
an instance in which an ovary contained twenty pints of pus. In 
a piliferous ovarian abscess which I saw in the practice of Prof. 
A. C. Post, at least half that quantity must have been evacuated 
by incision. As a rule, however, no such amounts are reached, 
from twelve to sixteen ounces being generally a large accumula- 
tion. 

1 N. Am. Med. and Surg. Journ., lS2o\ 



526 DISEASES OF THE OVAEIES. 

Causes. — Ovarian abscess may result from 
Acute ovaritis ; 
Tubercular deposit ; 
Eetention of debris of a foetus ; 
The scrofulous diathesis ; 
Piliferous or dermoid cysts ; 
Inflammation of walls of ovarian cyst. 
Tubercular deposit is very rarely found in the ovaries, as may 
be judged from the fact that Rokitansky 1 declares that he has 
never met with it, and is forced to deny its occurrence. Mme. 
Boivin's plates, 2 however, so fully illustrate one instance that its 
authenticity cannot be doubted. In a specimen presented me by 
Dr. Janeway, and which was exhibited to my class two years ago, 
tubercles existed in the lungs, liver, spleen, peritoneum, nterus, 
tubes, and, I think, ovaries, since the cheesy mass contained in 
these organs resembled precisely that in the other parts. 

The product of ovarian pregnancy is sometimes extruded by 
the process of suppuration not only from the gland but from the 
body. Mme. Boivin was the first to suggest the occurrence of 
suppuration in the walls of ovarian cysts, as a cause of abscess. 
Her theory is now accepted by pathologists as correct, 3 and 
explains instances of multilocular abscesses which have been 
sometimes seen. 

Symptoms. — Should ovarian abscess be the result of ovaritis, it 
will be marked by severe pain, chill, fever, throbbing, and the 
signs already mentioned. If it result from causes which produce 
no sudden excitement of circulation and nervous supply, no symp- 
toms other than dull pain, discomfort upon motion, and occasional 
fever may point to the lesion. It is only when a circumscribed 
tumor giving evidence of fluctuation is discovered that a diagnosis 
is warranted. 

Differentiation. — Even then it is often difficult, except in cases 
due to ovaritis, to distinguish the disease from the following : — 
Ovarian cyst ; 
Pelvic abscess; 
Ovarian pregnancy ; 
Distension of Fallopian tube by fluid. 

1 Path. Anat., vol. ii. p. 252. Am. ed. 2 Plate xvi. 

3 See Farre, Hewitt, &c, opera citata. 



OVAKIAN ABSCESS. 527 

Abscess may be differentiated from cystic degeneration of the 
ovary in most instances by signs, perhaps very obscure, of inflam- 
matory action ; tendency to chill and fever ; pain upon pressure ; 
and discomfort in certain attitudes. Pressure by conjoined mani- 
pulation will almost invariably cause pain, while in cystic disease 
it must be very severe for it to do so. 

From pelvic abscess a diagnosis is always difficult and very 
often utterly impossible. Kiwisch tells us to rely upon the im- 
mobility, excessive pain, and less defined boundaries of pelvic 
abscess, but where a certain amount of adhesive inflammation has 
been excited in ovarian abscess which has bound it to the sur- 
rounding parts the difficulty becomes insuperable. I have very 
recently had two cases, one seen with me by Drs. Emmet and 
Elliot, and the other by Dr. Metcalfe, in which a decision was en- 
tirely impossible, although, in both cases, the fact that the accu- 
mulation was purulent was placed beyond doubt by free and con- 
stant discharge of pus by a small opening in the vaginal wall. 

Ovarian pregnancy being marked by all the ordinary symptoms 
of conception, vomiting ; mammary signs, cessation of menstrua- 
tion, &c, will generally be suspected. 

From distension of the Fallopian tubes by watery mucus, blood, 
or pus it will generally be impossible to make a diagnosis with 
any degree of certainty. In some cases it may be accomplished 
by attention to the shape, configuration, and mobility of the tumor, 
as will be mentioned when speaking of dropsy of the Fallopian 
tubes. 

Treatment. — The suppurative process should in the beginning- 
be encouraged by poultices over the hypogastrium and irrigation 
of the vagina by warm water. So soon as the purulent mass has 
made its way to the surface of the abdomen, or of the vagina or 
rectum, it should be evacuated by a bistoury, or trocar and cannla. 
Then the strength of the patient should be sustained by quinine, 
brandy, beef-tea, milk, &c. Should the process of pus formation 
and discharge go on for too great a length of time, or should 
symptoms of septicaemia set in, the cavity of the abscess should 
be promptly injected with solution of tincture of iodine, persul- 
phate of iron, permanganate of potash, or carbolic acid. 



CHAPTEE XLII. 

FLUID OVARIAN TUMORS. 

The ovaries may be affected by three forms of tumor : — 
1st. Fluid tumors ; 
2d. Solid tumors ; 
3d. Composite tumors. 
The first class comprises those which are formed of one or more 
sacs filled with fluid contents only ; the second, those which are 
purely solid ; and the third, those which are composed of both 
solid and fluid elements. 

Strictly speaking, only those fluid tumors originating within the 
structure of the ovaries should be enumerated under this head, 
but since there are others which develop in the immediate vicinity 
and which cannot be differentiated, it will be of advantage for 
clinical purposes to consider them all as ovarian. 
The fluid tumors occurring in the ovaries are : — 
Hydatid cysts ; 
Ovarian cysts ; 
Cysts of the broad ligaments. 

Hydatid Cysts. 

Hydatid cysts may develop in the ovary, though the occurrence 
is so rare as to make an extensive consideration of them unne- 
cessary. The literature of the subject is very meagre, and in few 
of the works devoted to ovarian disorders is any mention of them 
made. In Dr. Bright's work upon Abdominal Tumors, fifteen 
instances of hydatid .tumors in the abdomen are recorded, in 
one of which a hydatid tumor the size of a very large hen's egg^ 
was connected with one ovary. Cruveilhier reports an instance 
discovered on the cadaver. Eoux and Deneux believed that they 
had operated upon such cases, the first by the rectum, the second 



OVARIAN CYSTS. 529 

upon a tumor imprisoned in the ingninal canal. Dr. Arthur Farre 
refers to a very large ovarian cyst, contained in the Museum of 
King's College, which consists of an immense aggregation of cysts, 
many of which are stuffed full of hydatids. Graily Hewitt 
believes that when hydatid disease of the ovaries exists, the echi- 
nococci are derived from the liver, and Kiwisch, who has never 
met with an instance, evidently suspects the authenticity of the 
reported cases, thinking that "torn off secondary cysts have been 
taken for acephalocysts." Too little is known of such cysts to 
warrant further remarks upon them. 

Ovarian Cysts. 

This variety of disease consists of the formation of one or more 
large sacs, developed within the substance of the ovary. 

Pathology. — Pathologists are still somewhat at variance with 
reference to the origin of ovarian cysts. "It was formerly very 
generally supposed," says Wedl, " that the cysts in the paren- 
chyma of the ovary originated in the Graafian follicles, but no 
direct proof of this was ever given." 1 On the other hand, Courty 
sums up the matter thus : "In a word, these cysts are dropsies, 
simple or complicated, of the Graafian follicles." 2 

There are probably two entirely different pathological processes 
by which they are generated. 1st. The follicles of De Graaf 
undergo a species of dropsy. The liquor folliculi, which they 
normally contain, becomes excessive, and distending the tunic 
and the discus proligerus which lines it, gradually creates a 
cyst. Cazeaux 3 once styled the Graafian follicles ovarian cysts in 
miniature, an aphorism which aptly illustrates this view. 2d. 
The development of cysts may occur in the sifroma, or upon the 
surface of the ovary, without connection with the follicles. To 
enter into a minute study of such cystic degenerations would be 
out of my province, and to avoid discussion and theories concern 
ing them, I will adopt the view advanced by Wedl, which recom- 
mends itself on account of its simplicity and plausibility. This 
I 

1 Wedl's Path. Histol.,p. 462. 

2 Op. cit.,p. 925. 3 These pour l'AgrSgation. 

34 



530 OVARIAN TUMORS. 

view supposes, that " the cyst consists in an excessive augmenta- 
tion of volume of the areolae of the areolar tissue and of the 
papillary new formations composed of connective tissue." 

Every cyst has three coats, one, external and serous, made up 
of the peritoneal lining of the ovary ; another, fibrous and vascu- 
lar, made up of the enveloping stroma, considerably altered ; and 
still a third, thin and shining, composed of fibrous structure, epi- 
thelial cells, and sometimes a deposit of cholesterine from the 
contents of the sac. Cases are on record in which the cyst wall 
has been an inch or an inch and a half thick. 

Generally upon the excessive development of cysts the ovary 
undergoes atrophy, but sometimes, instead of so doing, it becomes 
hypertrophied and superadds itself to some part of the sac, lead- 
ing to an erroneous opinion that the mass is cancerous. 

The fluid contained within these cysts differs greatly in chemi- 
cal and physical characters. Sometimes it is a clear, albuminous 
serum of light straw color ; sometimes it is thick, viscid, and 
adhesive ; while at times, it is a dirty brown and semifluid mate- 
rial. An analysis made of four specimens, 1st, clear, light straw 
color, alkaline ; 2d, dark-colored, muddy, and neutral ; 3d, like 
white of egg, alkaline ; 4th, clear, straw colored, by Dr. O. Eees, 
yielded in varying proportions the following elements : — 

Water ; 

Albumen with traces of fat ; 

Albuminate of soda ; 

Alkaline chloride and sulphate of soda from decomposed albu- 
minate ; 

Extractive, soluble in water and alcohol ; 

Chloride of sodium with carbonate, from decomposed lactate of 
alcoholic extract. In all the four specimens, albumen was detected. 

Varieties. — Fluid ovarian tumors may assume a variety of 
forms. Those which serve as types for classification are the fol- 
lowing : — 

Unilocular ; 
Multilocular ; 
Multiple. % 

The unilocular tumor consists of a simple dilatation of a Graafian 
follicle. This may go on until the size of the uterus in the ninth 



OVARIAN CYSTS. 531 

month of pregnancy is reached. Kiwisch 1 has met with one 
whose contents weighed over forty pounds ; but such a develop- 
ment is exceedingly rare, as they seldom remain simple after 
passing the dimensions of an adult head. 

Such cysts are much less likely than others to contract adhe- 
sions with the viscera of the abdomen, and they consequently 
constitute the most curable of all the varieties of ovarian tumor. 

Multilobular Cysts. — It has long been observed that from the 
walls of ovarian cysts, smaller cysts are likely to grow and pro- 
ject into the sac, more rarely, to develop externally and jut into 
the abdominal cavity. To this process of cyst growth Mr. Paget 
has given the names of endogenesis and exogenesis, and thus 
we speak of a tumor showing the former variety of growth, as 
an endogenous tumor, and of one showing the latter, as exoge- 
nous. Every cyst thus produced constitutes a loculus or cell, and 
gives to the previously simple sac the features of a multilocular 
tumor. 

Yarious theories have been advanced to explain this secondary 
cystogenesis. That which appears most plausible is that in the 
middle coat of the unilocular cyst, which is composed of stroma, 
undeveloped Graafian follicles exist. These, by the same process 
as that which resulted in the primary cyst, develop, and project 
inwards or outwards. Should they prove exogenous, they may 
subsequently rupture and create peritonitis, while should they be 
endogenous, their walls sometimes give way and a communica- 
tion is established with other vesicles originating as they did. 
These secondary cysts are likewise created by cell growth, which 
results in sac-like projections from the walls of the parent cyst. 
At first resembling warty growths, they jut farther forwards, 
increase in size, and become large cysts. 

Multiple cysts, as they have been aptly styled by Dr. Farre, are 
simply the development, side by side, of a number of Graafian 
follicles. These are bound together in the same envelope, and 
really constitute one tumor, although at the same time they are 
composed of a number of cysts which are perfectly independent 
of each other. It is true that intercommunication may take 
place, but this is an accidental occurrence due to rupture of the 
cyst-walls. 

Op. cit., p. 102. 



532 



OVARIAN TUMORS 



The fluid contained in multilocular and multiple ovarian 
tumors is not generally so clear as that of the simple or unilocu- 
lar variety. It is often as tenacious as honey or white of egg, 
so thick, indeed, that it will not flow through a large canula, and 
assumes very dark hues. At times it is colored by cholesterine, 
blood, or pus, and is brown, red, or like coffee-grounds. 

The size to which these cysts will grow is truly wonderful. It 
has been already stated that unilocular or monocystic tumors 
rarely attain a great size as such. They become, as they increase, 
multilocular or polycystic, and then their growth may become 
excessive. Instances are on record of tumors containing over 
one hundred pounds of fluid, and Dr. Copland, in the Diet, of 
Pract. Med. } tells of an instance in which five hundred pints of 
fluid were drawn off by repeated tappings, in twelve months. 

One or both of the ovaries may be affected, the right being 
that most frequently selected by the disease. The comparative 
frequency with which the right and left ovary is affected is shown 
by the following table : — 



Authority. 


No. of 
cases. 


Right side 
affected. 


Left side 1 

affected. Both sides. 


Safford Lee ...... 

Chereau ....... 

Scanzoni . . 


93 

215 

41 


50 

109 

14 


35 

78 
13 


8 
28 
14 



Causes. — Yery little is positively known upon this subject. 
The predisposing causes which are generally admitted are those 
which follow. It should be borne in mind that even as to some 
of these there is doubt and variance of opinion among Gyneco- 
logists. 

Age; 

Child bearing ; 

Chlorosis ; 

Scrofulous diathesis ; 

Menstrual disorders. 
The great predisposing cause is age, the affection showing 
itself almost invariably during the period of ovarian activity, 
and very generally during that of the most vigorous activity. It is 
rare under twenty and over fifty, the most common period of its 
occurrence being between twenty and forty. It may, however, 



OYAEIAN CYSTS. 533 

occur as early as thirteen or fourteen, and as late as sixty, and 
a slight degree of cystic degeneration has been seen in infancy. 

Scanzoni records 97 cases, 70 of which were from 18 to 40. 
Cherau " 230 cases, 133 " " " " 17 to 37. 

Lee " 135 cases, 82 " " " " 20 to 40. 

Of Scanzoni's cases five were between fifty-five ; and sixty of 
Lee's one hundred and thirty- five cases, eighty-eight were mar- 
ried, thirty-seven unmarried, and eleven widows. With refer- 
ence to the propriety of admitting the other causes there is much 
doubt. 

The uncertainty existing as to the exciting causes is even 
greater than this. All those influences which theoretically 
would be likely to excite cystic growth, as ovaritis, blows, check- 
ing of menstruation, excess of coition, libidinous desires without 
gratification, have been advanced by authors as scientific certain- 
ties. But proof is wanting, however plausible the theoretical 
reasoning appears, and they cannot in the present state of science 
be admitted. " Our knowledge," says Graily Hewitt, " of the 
pathology of cystic disease, as ordinarily witnessed in the ovaries, 
seems reduced to this : that it is the business of the ovary to 
secrete cysts — the Graafian follicles; that this process of secre- 
tion is occasionally disturbed and deranged, and that one result 
of this is the production of large cysts of pathological character." 
This is reducing our knowledge to simply nothing, and yet such 
appears to be its true position at present. Certainly nothing can 
with safety be predicated beyond this, that it is probable that 
those influences which keep up and intensify ovarian congestion, 
and interfere with rupture of the follicles of De Graaf, tend to 
produce cystic and follicular degeneration. 

Symptoms. — The symptoms which develop themselves in the 
course of the disease are due to three separate and distinct agen- 
cies : disorder in the diseased ovary, mechanical inconvenience 
from the abdominal mass, and complications caused by its pre- 
sence. The first demonstrates itself by dull pain over the iliac 
fossa, and a sense of fulness or throbbing. The second gives rise 
to dragging pains, dysuria, rectal disorder, and local fatigue after 
exertion. The third shows the ordinary signs of local peritonitis, 
which may become quite active and then subside. None of these 
except the last, which is an intercurrent accident, are generally 



534 OVARIAN TUMORS. 

very marked. They are usually only sufficient to suggest physi- 
cal examination, by which reliable signs will probably be dis- 
covered, and the diagnosis be made complete. 

Physical Signs. — These are of the greatest importance, and the 
full capacity of physical exploration should in every case be 
developed, for to it we must look for answers to the following 

questions : — 

1st. Does a tumor exist ? 

2d. If so, is it ovarian ? 

3d. If it be ovarian, what is its type? 

4th. If a fluid ovarian tumor, is it multilocular ? 

5th. Is it adherent to surrounding parts ? 
Does a tumor exist f — To decide this question, the patient should 
be placed upon her back upon a flat, resisting surface, the abdo- 
men uncovered, all stricture removed from the waist, and the 
knees drawn up so as to relax the abdominal muscles. It is of 
primary importance that she should be calm, and give herself up 
to the examination in the full desire of aiding the physician in 
arriving at a diagnosis. In some cases the patient, from nervous- 
ness, in some from pain created by pressure, and in others from 
a desire to mislead and deceive, will not be able or willing to do 
this, but, on the other hand, by suddenly contracting the abdomi- 
nal walls, will place a serious, perhaps insurmountable, obstacle 
in his way. Under such circumstances ether should be employed 
as an anaesthetic, and full investigation made. The abdominal 
muscles being entirely relaxed, careful palpation and deep pres- 
sure should be made by both hands over the whole abdomen, 
and especially over the pelvic region. By this means a hard, 
resisting mass may be discovered, which produces an abdominal 
enlargement visible upon inspection. 

Thus far very little has been learned ; merely that an abnormal 
enlargement exists in the abdomen. It may not deserve the sig- 
nificant name of tumor, but be due to one of these states : — 
Adipose deposit in abdominal walls ; 
(Edema of abdominal walls; 
Tympanites. 
Yery little experience will enable one to eliminate the first 
from consideration. An equable, smooth mass will be felt spread 



^^iBBI 



OVARIAN CYSTS. 535 

over the whole abdomen, yielding upon percussion resonance, 
which comes from air in the subjacent intestines. The most 
certain method of recognizing the condition will consist in lifting 
in the fingers or hands a large fold of the mass. 

(Edema will be known by pitting upon pressure, by existence 
of the same condition in the areolar tissue of the feet or face, and 
by its generally attending urasmia, chlorosis, or cardiac disease. 

Tympanites will be readily recognized by extreme resonance 
upon percussion over the whole abdomen. 

It having now been decided that the patient has an abdominal 
tumor, or, in other words, an abdominal swelling due to a mor- 
bific cause of serious nature, it next becomes important to decide, 
not as to the character of such tumor, but whether it be ovarian 
or not. 

Is the tumor ovarian? — It has been already stated that any 
abdominal tumor may, unless careful means of differentiation are 
adopted, be confounded with ovarian growths. The truth of this 
may be judged of by reference to the valuable tables of Dr. John 
Clay, the translator of Kiwisch on the ovaries. He has collected 
twenty-three cases of attempted ovariotomy in which the opera- 
tion was abandoned because the tumor proved not to be ovarian. 
The tumors were of the following characters : — 
12 were uterine ; 

2 " omental ; 

2 " results of chronic peritonitis ; 

2 " not discoverable ; 

1 was tubal pregnancy ; 

1 " obesity ; 

1 " mesenteric ; 

1 " splenic ; 

1 " not stated. 
This part of our subject would be uselessly prolonged by an 
examination of the means of differentiating all forms of abdominal 
tumor, as, for example, enlargements of the liver, spleen, &c. All 
that I conceive it necessary to do is to enumerate those affections 
likely to be confounded with ovarian tumor by a practitioner of 
reasonable capacity, and point out the reliable means of distin- 
guishing these. The following is a list of them : — 



536 OVARIAN" TUMORS. 

Fecal accumulation : 

Extra-uterine pregnancy ; 

Normal pregnancy ; 

Uterine fibroids ; 

Ascites ; 

Hydatids ; 

Distension of uterus by fluids. 
Fecal matters sometimes accumulate to a great extent in the 
caput coli, and even along the course of the large intestine. A 
little care will generally serve to distinguish such a tumor from 
one connected with the ovary. One or two fingers made to im- 
pinge with force upon it per vagi nam, while it is steadied by the 
other hand placed on the abdomen, will reveal its plastic, " boggy" 
nature. Should any doubt exist, a course of catharsis would 
remove it. 

Pregnancy, whether uterine or extra-uterine, affords abundant 
evidences of its existence in the rational and physical signs of that 
state. Should doubt exist here, a little delay will decide the 
diagnosis fully. Error is likely to arise in reference to differ- 
entiating this state, either from the possibility of its presence 
being lost sight of, or from the examiner placing reliance upon 
the asseverations of a woman who has every inducement to 
deceive. 

To state that there are many difficulties attending the differ- 
entiation of uterine fibroids from ovarian tumors, would be to 
leave on the mind of the inexperienced practitioner a very im- 
perfect and erroneous impression. It is not only difficult but often 
utterly impossible, even for the most capable and accomplished 
diagnostician to arrive at a certain conclusion. Quite a number 
of cases are now on record where not only have experienced 
operators opened the abdominal walls under an erroneous impres- 
sion as to the nature of the tumor, but absolutely removed the 
morbid growth and the uterus from which it grew before a diag- 
nosis was made. Fortunately this obscurity is exceptional. In 
most cases the origin of the tumor may be determined by the 
following means : — 



OVARIAN CYSTS 



537 



In Uterine Fibroids. 
1st. There is usually menorrhagia ; 

2d. The uterus, measured by the 
sound, is enlarged ; 

3d. Mass felt per vaginam is irregular 
and continuous with uterus ; 

4th. There is often leucorrhoea ; 

5th. Sound placed in utero and made 
to move the uterus, the tumor felt by 
hand on abdomen moves also ; 

6th. The uterus is generally displaced ; 



7th. There are often several tumors 
8th. The tumor is always hard. 



In Ovarian Tumors. 
1st. Menorrhagia does not exist as a 
symptom ; 

2d. Uterus is not enlarged ; 

3d. Mass felt per vaginam is smooth 
and not continuous with the uterus ; 

4th. There is no leucorrhoea ; 

5th. The uterus may be moved with- 
out the tumor moving ; 

6th. The uterus is not so markedly 
displaced, although it may be somewhat 
so ; 

7th. There is generally only one tumor ; 

8th. The tumor, if of fluid type, fluctu- 
ates. 



From abdominal dropsy or ascites a differentiation is often 
extremely difficult, and always so important that a careful con- 
sideration is necessary. 



In Ovarian Dropsy. 

1st. A small, round tumor will have 
shown itself in the beginning in one iliac 
fossa ; 

2d. In supine posture a rotundity is 
observed in the abdomen ; 

3d. Percussion made in supine pos- 
ture gives dulness over surface of abdo- 
men ; 

4th. Change of posture alters line of 
dulness but little ; 

5. No pouching and fluctuation are 
noticed by vaginal touch of Douglas's 
cul-de-sac ; 

6th. No evidences of cardiac, renal, or 
hepatic disease exist ; 

7th. Skin is normal as to color, mois- 
ture, &c. ; 

8th. Patient rolling in bed, no wave 
will be detected by inspection. 



In Ascites. 
1st. The enlargement will have shown 
no small tumor at any point ; 

2d. In supine posture the fluid gravi- 
tates to sides of abdomen, and the abdo- 
minal surface is flattened ; 

3d. Percussion gives resonance over 
abdominal surface because the intestines 
float on the fluid ; 

4th. Change of posture greatly alters 
line of dulness ; 

5th. Douglas's cul-de-sac is pouched 
by fluid which fluctuates ; 

6th. Evidences of cardiac, renal, or 
hepatic disease almost always exist ; 

7th. Skin, in majority of cases gives 
evidences of cirrhosis by its parchment 
feel and jaundiced hue ; 

Sth. Patient rolling in bed, a wave will 
be detected in the abdomen. 



From hydatids in the abdomen, the diagnosis of ovarian tumor 
will generally be practicable only by explorative incision, unless 
those growths be developed only upon the organs in the upper 



538 OVARIAN TUMORS. 

part of the abdomen. If the mass collect above the ovaries, if 
the patient be not a menstruating woman, or if snch a develop- 
ment have been detected elsewhere in the system, all these con^ 
siderations will, of course, prove of great weight in deciding the 
point. Dr. Bright, in his work upon Abdominal Tumors, gives 
illustrations of this affection, the differentiation of which from 
ovarian tumors would have been entirely impracticable unless the 
cases had been seen early and kept under observation. 

The tumor being ovarian, what is its type ? — It must, of necessity, 
be either a fluid tumor, a solid tumor, or one of composite cha- 
racter. Should it be of the first form, its character will be ascer- 
tained by fluctuation being yielded perfectly all over its surface, 
and also by vaginal palpation, which is performed by placing one 
ringer on the tumor where it rests against the roof of the pelvis 
and tapping with the other hand upon the abdominal wall. Should 
it be solid, the sense of resistance everywhere felt and the absence 
of fluctuation would proclaim the fact. A composite tumor, or 
one solid in some parts and fluid in others, would be recognizable 
by a union of the features mentioned as characteristic of each of 
the other varieties. 

These are the means by which a classification of the tumors 
must be made, but let it not be supposed that the task is always 
an easy or even a practicable one. There are certain forms of 
cancer, the medullary, for example, which yield, to all appearances, 
the characters of fluidity and yet contain solid elements. This is 
so even with cystic sarcoma. About a year ago I. saw, in con- 
sultation with Dr. Peaslee, whose name as an ovariotomist has 
become so justly celebrated, a lady from Texas, in whose abdomen 
there existed a large and apparently fluctuating tumor which we 
supposed to be ovarian. It was by Dr. Peaslee exposed by inci- 
sion and found to be a cystic sarcoma connected with the uterus. 
The case ended fatally, removal of the tumor proving impossible. 

I once saw, with Dr. John O'Eeilly, an immense tumor, evi- 
dently of the ovary, in which fluctuation was clear, yet upon 
removal a cystic sarcoma was discovered to have yielded the 
delusive sign. 

On another occasion I had a patient presenting all the usual 
signs of fluid ovarian tumor so perfectly that Drs. Peaslee, Loomis, 
Budd, and myself had no doubt as to the fact. Upon incision and 



OVAKIAN CYSTS. 539 

tapping no fluid flowed, and I removed a cystic sarcoma of fourteen 
pounds weight. As it lay upon the table after the operation it 
was examined by a number of physicians, and nothing could 
convince them even then that its contents were not fluid, except 
section of the mass. 

Wherever doubt exists there is one, and but one, means by 
which it may be entirely removed, and that is an explorative 
tapping. This may be done through the vaginal or abdominal 
walls by a small exploring trocar, and sufficient information ob- 
tained to put the question at rest. Such an exploration is in these 
cases always legitimate, for it is not attended with great risk, 
and yields important results. 

Is the tumor, which is now regarded as fluid ovarian, multilocular ? 
— "We need not stop to inquire very closely into the means for 
ascertaining whether it be hydatid ovarian cyst, true ovarian cyst, 
or Wolffian cyst, for at the bedside these questions do not often sug- 
gest themselves. The reason for this is, that hydatid cysts of the 
ovaries are merely curiosities, thus far in professional experience, 
which have been seen by very few even of the most experienced 
ovariotomists. Wolffian cysts and dropsies of the Fallopian tubes 
do not, as a rule, grow as large as ovarian cysts, but otherwise 
there are no means except explorative incision which can differ- 
entiate them. The same remark is especially applicable to areolar 
cysts of the broad ligaments, between which and true ovarian cysts 
no diagnostic signs exist except those obtainable after incision. 

The question as to the tumor being unilocular or multilocular 
is of importance, for the prognosis of the former is more favor- 
able with reference to operative procedure than that of the latter. 
The following signs will be our surest guides to a determination 
of this question : — 

Should a polycystic tumor be exogenous, the cysts outside of 
the original parent cyst may be felt by palpation. Should it be 
endogenous, however, this means would fail us. 

Although in a few instances large unilocular tumors have been 
seen, for example, one by Kiwisch of forty pounds, almost all 
ovarian cysts after passing the size of the adult head become 
multilocular. 

If explorative tapping give a tenacious or honey-like fluid, the 



540 OVARIAN TUMORS. 

tumor is probably multilocular ; if a clear, straw-colored liquid, 
it is probably unilocular. 

Is the tumor adherent to surrounding parts f — In many cases this 
can be determined only by explorative incision, but in a certain 
number it may without this be decided with an approximation to 
certainty that firm adhesions do or do not exist. The following 
are the grounds upon which an opinion may be based : — 

If the case has developed very rapidly and is believed to be 
unilocular, there are probably no adhesions. 

If there have been symptoms of peritonitis, there are probably 
adhesions. If the case has been painless, there are probably none. 

If the abdominal walls roll freely over the tumor, the patient 
lying upon her back, and should the tumor fall low in the abdo- 
men as she suddenly sits up, there are probably no anterior 
adhesions. But posterior ones may exist and not be suspected 
from this examination. 

If, upon vaginal examination, the uterus and base of the tumor 
exhibit immobility such as is found in pelvic peritonitis, and if, 
upon change of posture from erect to supine, these parts do not 
retreat from the finger in the vagina, there are in all probability 
strong pelvic adhesions. 

All these signs are unreliable, and disappointment will surely 
follow any great degree of confidence which is reposed in them, 
but a compensation is to be found in the fact that even firm adhe- 
sions do not contraindicate removal. 

Natural History. — Ovarian dropsy develops either by one or by 
a number of cysts. In the first case the cyst may become fully 
distended by fluid, reach a point where its growth ceases and 
remain quiescent, only annoying the patient by the mechanical 
results of its presence and the apprehension that it may increase 
and create trouble. There are no grounds for doubting the evidence 
that such tumors may remain without increase for even forty or 
fifty years, but such cases are rare exceptions to a general rule. 
"Much mischief has resulted, however," says Dr. Graily Hewitt, 1 
" from looking on such cases as the typical ones, while the large 
majority of the cases, the end of which is naturally death in a 
much shorter time, have been considered as the exceptional ones." 

1 Op. cit., p. 585. 



OVARIAN CYSTS. 541 

We now and then meet with pulmonary tuberculosis which 
goes on to formation of a large cavity, and then for some unac- 
countable reason ceases to advance. The cavity, which is dis- 
tinctly discernible, remains quiescent, and the patient may live for 
years. As this is an exception in the natural history of phthisis, 
so is the tardy course of ovarian dropsy just alluded to, an ex- 
ception to the usual course of that affection. Generally the mono- 
cyst as it grows develops the power of cysto-genesis and becomes 
polycystic. If its type be originally multiple, the tumor advances 
even more rapidly, certainly, and uncontrollably than in the case 
just mentioned. The prognosis of ovarian dropsy uninterfered 
with by art, and by this we mean surgical art, as medicine has no 
controlling or curative power in the disease, is always unfavorable. 
In the great majority of instances unilocular disease changes its 
character to multilocular, and the average duration of the cases of 
both is supposed by the best modern authorities to be about 
three years of life after the inception of the affection. 

Mr. Safford Lee 1 has collected the statistics as to the duration 
of the disease in 123 cases, uninterfered with by curative surgical 
means. 

In 38 the duration was ..... 1 year. 

" 25 " " " 2 years. 

u 27 » << « 3 « 

"10 « " " 4 " 

" 4 " " " 5 " 

" 5 " " " 6 " 

« 4 » " " 7 " 

" 3 " " " 8 " 

" 17 " " " 9 to 50 

From this it will be seen that out of 123 cases 80 terminated 
within three years, and 94 within five. At the same time it must 
not be lost sight of that 17 out of 123 cases lasted over nine years, 
and that some, the number of which is not stated, terminated at 
the end of fifty. Sometimes nature effects a cure in the following- 
ways. The cyst may discharge into the peritoneum and absorp- 
tion occur. Of this accident Dr. Tilt Las collected 71 cases, of 
which 30 recovered, 19 were improved, and 21 died. I have met 
with two instances of rupture, both of which proved fatal by 

1 G. Hewitt, op. cit., p. 5S4. 



542 OVARIAN TUMORS. 

peritonitis. The cyst walls may undergo calcareous degeneration 
which checks advance. The cyst may discharge externally by the 
abdominal or dorsal surfaces, or into the rectum, bladder, vagina, 
or uterus, by means of the Fallopian tubes. Instances of the last 
occurrence are mentioned by Morgagni, Frank, Follin, and Boi- 
vin, and Eichard records five cases. Again, palliative surgical 
means may prove curative. There is a limited number of cases 
on record in which paracentesis has produced a favorable result. 

"With reference to nature's power alone, or aided by absorb- 
ents, to remove the accumulated fluid, Kiwisch 1 declares, " We 
must express our dissent from the opinion of those practitioners 
who assume that an ovarian cyst can be completely removed by 
simple absorption. So far as we know, this process has not been 
satisfactorily demonstrated by a single case." M. Courty, how- 
ever, relates two instances in which cure was effected by medical 
means. 

There are several modes in which ovarian dropsy produces its 
usual fatal results when unchecked by surgical means. 

1st. A cyst may rupture and produce peritonitis. 

2d. The patient may die from exhaustion, the result of func- 
tional derangements. 

3d. Organic diseases produced by mechanical agency of the 
tumor may destroy life. 

4th. The opening made by tapping may give exit to a discharge 
which exhausts the patient by its long continued drain. 

Before leaving this part of the subject it may be well to sum up 
the grounds upon which a prognosis may be safely made : — 

If the patient be young, the prognosis as to rapidity and cer- 
tainty of growth is bad ; 

Unilocular tumors are most favorable ; 

Antecedent slow growth is favorable ; 

Solid matter in tumor is favorable as to growth, unfavorable 
as to cure ; 

The occurrence of the menopause is favorable ; 

Interference with surrounding organs, as the rectum, bladder, 
kidney, or stomach, is highly unfavorable ; 

A tumor firmly bound in the pelvis causes an unfavorable 
prognosis. 

1 Op. cit., p. 119. 



OVARIAN CYSTS. 543 

Treatment. — The medical treatment of ovarian dropsy by diure- 
tics, hydragogue cathartics, diaphoretics, mercurials, absorbents, 
mineral waters, &c, has now been faithfully tested and found to be 
inefficacious. After a careful search through the records of the 
subject, one is forced to the conclusion, that an extremely limited 
number of cases exists substantiating the possibility of the accom- 
plishment of absorption by these means. All that can be antici- 
pated in these cases from medication, is sustaining the nervous and 
sanguineous systems by tonics and stimulants; overcoming disor- 
dered function by diaphoretics, cathartics, diuretics, and anti- 
emetics; and relieving local inflammations by the ordinary means 
usually resorted to under such circumstances. I am the more 
urgent in insisting upon the fact of the in efficacy of constitutional 
treatment, because I rarely meet with a fully developed case of ova- 
rian dropsy at my public clinique which does not bear evidence of 
a variety of attempts by cupping, leeching, blistering, inunction, 
painting with iodine, and correspondingly active internal treat- 
ment, to dissipate the accumulation. There is but meagre proof 
extant that such means have effected cures, and there is nothing 
more certain than that they lower the tone of the system and de- 
preciate the vital forces. A recognition of this fact led Dr. W. 
Hunter, 1 before the introduction into practice of the present 
methods of surgical treatment, to say that "the patient will have 
the best chance of living long under it, ovarian dropsy, who does 
the least to get rid of it." 

It is to surgery that we must look for aid, and the following 
list represents the means at our command. It does not by any 
means represent all the measures which have been proposed and 
practised, for to do so would be to trammel the mind of the reader 
with much that would be of no practical importance. Only those 
methods are recorded which are to-day regarded as well recog- 
nized and reliable procedures : — 

Tapping ; 

Drainage ; 

Incision ; 

Injection of the sac; 

Partial excision ; 

Ovariotomy. 

1 Baker Brown, op. cit. 



544 OVARIAN TUMORS. 

Tapping. — The operation of paracentesis, or tapping, consists 
of the introduction of a trocar and canula through the walls 
of a sac containing fluid, and allowing this to flow away. Of all 
the operations for relief of ovarian dropsy this is the oldest, and 
has been that most frequently performed. The advantages which 
it offers are, facility of performance, quickness of relief, and im- 
munity to a certain extent from the dangers which attend other 
surgical procedures adopted in these cases. It likewise enables 
us to decide with certainty with reference to the diagnosis of the 
disease. 

It is, however, attended by serious disadvantages, and although 
in a limited number of cases it has proved curative, it should never 
be practised with any reliance upon its doing so, for in the great 
majority of instances it is purely palliative. Furthermore it is 
attended by the immediate dangers of hemorrhage and peritonitis, 
and by the more remote one of exhausting discharge from the 
sac which may continue so long as to wear out the patient's 
strength. M. Courty collates one hundred and thirty cases treated 
in this way by Kiwisch, Lee, and Southam, of which these are 
the results : — 

46 died after the 1st tapping. 

10 " " 2d 

25 " " 3d to 6th tapping. 
15 " " 7th " 12th " 
13 " " the 12th " 

Of 20 of these cases by Mr. Southam, 4 died within a few hours 
after the operation, 3 within the first month, and 14 within nine 
months. Kiwisch lost nine out of 64 within twenty-four hours 
after the first tapping. Dr. Fock, 1 of Berlin, gives the following- 
table, displaying the dates at which death occurred after first 
operation in 132 patients. 

25 died within a few days. 
24 " " 6 months. 
22 " u 12 " 
21 " " 24 " 

11 " " 36 " 

29 only were alive at end of last date. 

132 

1 Simpson, op. cit.. p. 347. 



TAPPING. 545 

It will thus be seen that reliable statistical evidence places this 
procedure in the position of a palliative means which is uni- 
formly followed by advance of the disease, and not rarely by im- 
mediate evil results. Still it must not be lost sight of that by the 
operation death may be warded off, many existing evils alleviated 
through the course of a period, varying from ten to twenty-five 
years, and that, in a few cases, complete cure has been effected. 
Dr. Eamsbotham records an instance in which one hundred and 
twenty-nine tappings were performed in eight years, and four 
hundred and sixty-one gallons of fluid removed; and Dr. Martineau 
another, in which eighty operations gave vent in twenty-five years 
to seven hundred and twenty-nine gallons. 

In stating, on a previous page, that a limited number of cases 
attested the curative results of tapping, I would not be under- 
stood that such cases are in themselves very rare. They are 
really not so ; it is only in proportion to the cases tapped that 
they are limited in number. Prof. Simpson reports two cases, and 
Prof. Scanzoni three, in which a single tapping was followed by 
complete recovery. A similar case has been reported to me by 
Dr. Finnell, of this city, as having occurred in the practice of Prof. 
Bedford. Mr. Baker Brown thinks that most of such cases were 
instances of Wolffian or Fallopian sacs, and not actually ovarian 
dropsy. But such sacs are usually not large, and probably some 
of the instances on record were not of those forms. Take, for 
example, the following by Kiwisch : "We saw this favorable 
result set in after the second puncture of a colossal ovarian cystoid, 
which Prof. Pitha performed in such a manner that the tumor 
which had previously contained more than sixty pounds of fluid, 
became shrivelled to the size of a child's head, and for six years 
caused the patient no inconvenience at all, who had formerly been 
reduced to the last extremity, but now is very well." 

The circumstances which indicate the propriety of paracentesis 
are, rapid accumulation which interferes with some important 
function ; coexistence of ovarian disease with pregnancy ; solitary 
character of the cyst ; firm adhesions which bind the tumor down 
so as to prohibit a more radical procedure ; great doubt as to diag- 
nosis; or constitutional debility which prevents the tolerance of a 
more serious operation. The operation may be performed through 
the abdominal, vaginal, or rectal walls. 
35 



546 OVARIAN TUMORS. 

Tapping through the abdominal walls. — The patient being 
placed upon the side, a many tailed bandage, such as is employed 
in paracentesis abdominis, is passed around the body. Its ends 
being held by assistants, traction upon them makes firm pressure, 
evacuates the tumor, and prevents syncope. By means of a bis- 
toury, a small incision, a quarter of an inch in extent, is made upon 
the linea alba, midway between the symphysis pubis and umbili- 
cus. A large and long trocar is then plunged through the two 
layers of peritoneum and the wall of the cyst. Through the canula 
thus introduced a flow of fluid will take place which, if such an 
instrument as that represented in Fig. 203 is employed, will be 
conducted by an India rubber tube attached to the canula into a 
tub placed by the side of the bed upon which the patient lies. 




Fig. 204. 




Should this canula not be employed, a convenient vessel may be 
held under the stream and emptied into a larger one when it is 
filled. 

Should other cysts be felt through the abdominal walls after 
emptying the main one, the trocar may be again introduced and 
the canula made to empty them. 

In performing the operation the practitioner should remember 
that one of the greatest dangers resulting from it is the occurrence 
of peritonitis. It is highly probable that this is excited not by the 
puncture but by subsequent escape into the peritoneum of fluid 
from the sac. To prevent this all the fluid should be removed 
which can possibly be gotten out before removal of the canula. 
Dr. Peaslee suggests washing out the sac with tepid water, and 
practises it in all his cases where the fluid is viscid. "When the 
tumor is emptied of its contents, the abdominal wound should be 



TAPPING THROUGH THE WALLS OF THE VAGINA. 547 

closed by one or two silver sutures, the bandage tightened, a fall 
dose of opium administered, and the patient kept quietly upon her 
back for at least a week. During this time the bowels should be 
kept constipated, the bladder evacuated by the catheter, and every 
influence which could excite peritonitis carefully guarded against. 
The dangers which follow the operation have been mentioned ; 
those which attend its performance are perforation of the blad- 
der, injury to the uterus or one Fallopian tube, and wounding the 
epigastric artery, or some large vessel of the cyst. The last can- 
not be helped, while the means for avoiding the first three acci- 
dents are self evident. Kiwisch asserts that there is seldom union 
between the wound in the cyst and the abdominal wall as a result 
of the operation. 

Tapping through the walls of the vagina. — This operation has been 
more or less in vogue for a long time. According to Kiwisch, 
it was first performed by Callisen in 1775, but has received little 
notice until modern times. Velpeau 1 declares that he advised 
it in 1831, and that it was adopted a few years afterwards by 
Nonat, Neumann, and Kecamier. In Germany it has of late 
years been frequently resorted to, and Scanzoni gives the follow- 
ing reasons for preferring it to abdominal paracentesis. It " more 
often produces a radical cure than the other method just con- 
sidered, and that especially because the cyst, opened in its lowest 
part, can empty itself more completely. If the puncture by 
the vagina was always possible, the abdominal puncture would 
soon entirely disappear from chirurgical practice ; but, unfortu- 
nately, this is not the case — for the conditions necessary for this 
operation are met with in but few patients ; in fact, it is rare that 
the lower portion of the tumor descends sufficiently low into the 
pelvis to be accessible to the vaginal touch, and, furthermore, in 
many cases where the tumor can be reached, it does not present 
in its lower portion any cavity filled with liquid, but only solid 
masses of a sarcomatous, colloid, or cancerous nature." Kiwisch 
declares that he " unconditionally" prefers it to abdominal tap- 
ping, whenever it is practicable. 

The advantages of this operation will be appreciated by the 
following considerations. The wound made by the trocar in 

t ' Diet, de Med., torn. xxii. p. 589. 



548 OVARIAN TUMORS. 

the walls of the abdomen is readily united by suture, but that in 
the cyst wall remains open, and allows fluid to pour into the 
peritoneum. Should this be of a bland character, it is readily 
taken up and eliminated by the emunctories ; but should it be of 
an irritating nature, it creates peritoneal inflammation which may 
go on, as has been shown, to a fatal issue. It is very evident that 
if the puncture be made in the most dependent portion of the 
peritoneal sac, the danger resulting from this condition will be 
diminished. 

The operation is thus performed: the bladder and rectum 
having been carefully emptied, and the patient anaesthetized, she 
should be placed upon a table in the position for lithotomy. The 
operator then introducing the index, or, as is better, the index 
and middle finger of the left hand, places them against the most 
dependent and accessible part of the tumor. Upon the finger or 
fingers, a canula ten inches long is passed up and pressed against 
the tumor, the point of the trocar being drawn in a little. The 
operator then plunges the trocar through the vaginal walls into 
the tumor, and withdrawing it allows the fluid to flow away 
through the canula. The patient is then put to bed, quieted by 
opium, and guarded against all influences which might induce 
inflammation as long as such an accident is probable. 

Tapping through the rectum. — Should the surface of the tumor 
be more accessible through the rectum than the vagina, or if 
for any other reason, as, for example, constriction, atresia, or 
inflammation of the vagina, it be deemed best to pierce the rectal 
wall, there is no objection to doing so. Should a choice be 
admissible, however, no special reason pointing to the rectum as 
the proper point of approach, it will be best to operate through 
the vagina. From this canal, fluids pour without effort on the 
part of the patient, and without annoyance to her, while from 
the rectum they can pass only by a voluntary act which exhausts 
her strength, and annoys her by the necessity for frequent repe- 
tition. 

Thus far the operation of paracentesis ovarii has been investi- 
gated merely as a palliative procedure, proving curative only 
exceptionally. The evil which is most uniformly active in pre- 
venting its curative effects, is rapid reaccumulation of fluid in 
the cyst. Indeed, the operation often seems to give vigor to this 



DRAINAGE. 549 

process, and as each accumulation robs the blood of some of its 
nutritious elements, a repetition of the act of emptying the sac 
rapidly exhausts her strength. The observation of this fact has 
led to the adoption of the method of which we come next to 
speak. 

Drainage. — This operation consists merely of vaginal or abdo- 
minal paracentesis, enlargement of the opening made by the 
trocar, and the introduction and maintenance of a tube in the 
canal thus created, by which fluid can flow out and injections be 
thrown in. 

The proposition of vaginal paracentesis already mentioned 
as claimed by Velpeau, in 1831, was not confined to evacuation 
of the sac, but comprehended its drainage by means of a tube 
left in situ, if such a procedure was deemed necessary. In more 
recent times the gynecologists of Germany have systematized the 
operation, and rendered it subservient to the best practical re- 
sults. It presents, of course, all the advantages of evacuation of 
the contents of the sac by vaginal opening, while at the same 
time it obviates the chances of failure resulting from reaccumu- 
lation and redistension. Statistics with reference to it are not 
yet sufficiently complete or full to enable us to speak with entire 
confidence of it, but thus far its results have been of the most 
flattering character in a certain kind of case. No one claims for 
it an extended field of usefulness. Even Kiwisch, its introducer 
and strongest advocate, speaks thus guardedly on this point : " In 
our opinion it is only of use in moderately large, simple cysts ; 
because, in very large cysts, the extensive decomposition must 
be very exhausting to the system, and compound cysts do not 
allow of a proper shrivelling of the open sac, as we experienced 
in a fatal case in which two cysts were in juxtaposition, and only 
one could be punctured." 

Scanzoni has operated in this way fourteen times ; eight cases 
were cured ; two relapsed in a few weeks ; three were lost sight 
of, and one died of typhoid fever two months after the operation. 

In America, the operation has been frequently resorted to by 
Dr. Emil Noeggerath. His success has not been flattering thus 
far, but he is favorably impressed in regard to the plan, and 
attributes his unfavorable results to the fact that the cases upon 



550 OVARIAN TUMORS. 

which he has operated have most of them been complicated by 
malignant or other serious disease. 

Kiwisetis method of practising drainage. — The operation of para- 
centesis vaginalis is performed as already described. The fluid 
of the cyst having flowed off, a director without a handle is 
passed into the sac through the canula, and held in position while 
the canula is removed. A long probe-pointed bistoury is then 
passed by means of the director, arid an incision is made, suffi- 
ciently large to introduce the index finger. The bistoury and 
director are then withdrawn, and a long flexible tube inserted 
which is allowed to hang out of the vagina, being fastened by a T 
bandage at the vulva. 

After the operation the patient should be kept in bed. On the 
second or third day symptoms of inflammation generally manifest 
themselves by severe reaction, and during ten or twenty days there 
is often an ichorous discharge and great pain in the surrounding 
parts. In favorable cases the ichorous discharge generally gives 
place to one which is purulent, and which disappears in from five 
to seven weeks, when shrivelling and perfect obliteration are to 
be expected. As long as there is any discharge from the cyst it 
should be washed out twice a day by an injection of lukewarm 
water, or, what is better, of warm water holding in solution per- 
sulphate of iron or carbolic acid. At thesame time copious vaginal 
injections should be used to prevent irritation of the vagina. 

The tube should be kept in place until discharge ceases and 
diminution of the sac has occurred. 

Schnetterh method. — Dr. Schnetter, of this city, has modified this 
procedure in the following manner : the canula being introduced 
and the trocar withdrawn, a little knife, one inch and a half 
long in the blade, fixed upon a handle constructed according to 
the curve and dimensions of the canula, but longer than it, is 
passed through it. As the handle of the knife is longer than the 
canula, this admits of a protrusion of the cutting surface beyond 
its mouth. In withdrawing both canula and knife an incision is 
made by the latter which opens the way for the finger and the 
drainage tube. Scanzoni, who has twice employed Schnetter's 
method, prefers it to that of Kiwisch, on account of its greater 
simplicity. 

West's method. — Still another method has been recommended 



west's method 



551 



by Dr. West, of London, which is simpler than either of those 
mentioned. The trocar and canula being plunged into the cyst, 
the former is removed and the fluid allowed to flow away. Then 
a No. 12 gum-elastic catheter is passed through the canula, the 
canula withdrawn, and the catheter fixed in its place by a T 
bandage. 

The cyst may be opened by Scanzoni's long trocar and canula 
or by a long bistoury. 




Fig. 207. 



Scanzoni's trocar and canula. 
Fig. 208. 




Maisonneuve's trocar and permanent canula. A, curved trocar with lancet point, with 
canula pierced at its extremity by three openings ; through one, after removal of the trooar, 
fluid pours, while through those on the sides the bent extremities of the elastic wires C C 
are put so as to prevent the escape of the canula. (Wielaud and Pubrisay.) 



552 OVARIAN TUMORS. 

The most ingenious apparatus which has been invented for the 
accomplishment of drainage by the vagina is represented by 
Fig. 208. 

Drainage, as has been already intimated, may be practised 
through the abdominal walls, either by a stiff or elastic tube. 

Incision. — In some cases of desperately bad character, the multi- 
locular nature of the sac renders tapping, drainage, and injection 
ineffectual for the accomplishment of cure, while extensive adhe- 
sions bind it to the abdominal walls so firmly that extirpation is 
inadvisable. Under such circumstances the operation of incision, 
which consists simply in laying open the tumor by cutting through 
the abdominal walls, may be resorted to. 

This operation, which is only one method of accomplishing 
drainage, is attended by many dangers and annoyances to the 
patient, who is often forced to submit to an exhausting and offen- 
sive discharge for months after its performance. It was first per- 
formed by Le Dran, a very graphic and minute description of 
whose procedure is given by Dr. Baker Brown. He performed 
it in 1836, making an incision about four inches long through 
the walls of the abdomen into the tumor, which he kept open for 
five months with pledgets of lint and a canula of sheet lead. 
Should it be found advisable after abdominal incision to adopt this 
method, if complete union does not exist between the cyst and 
abdominal peritoneum, the lips of the former may be sewed to 
the latter ; a method advised by Mr. Baker Brown. Before making 
the abdominal opening, it has been advised by Kecamier, and more 
recently by Tilt, to cause, by means of caustic issues, pathological 
adhesion between the sac and abdominal wall, but the plan has 
not met with success. 

I had endeavored to present a statistical table of the results of 
this plan of drainage, but so difficult have I found it to distinguish 
between the reports of it and of simple tapping in which the 
opening has been left unclosed, that I am forced to offer it only 
as an imperfect report of a certain number of cases treated by 
incision : — 



incision. 553 

No. op 

Operator. Cases. Cured. Died. 

Le Dran 2 2 

I. B. Brown 3 3 

De Laporte 1 1 

Velpeau 1 1 ° 

Portal 1 1 

Bonnemain 1 1 

Ray 1 1 

Bainbridge 2 1 1 

Mussey 1 1 

Prince 1 1 

Djondi 1 1 

Galennowsky 1 1 

Buhring ........ 3 1 2 

Pagenstecher ....... 1 1 

Ollenroth 1 1 

Douglass 1 1 

Clay 2 2 

Farrell 1 1 

Hutchinson ........ 1 1 

Paget ...1 1 

Trowbridge ........ 1 1 

Weber 1 1 

Thomas 1 1 

30 19 11 

In some of these cases the entire sac was filled with pledgets of 
lint saturated with caustic solutions ; in some, threads of worsted 
or other substances were rolled into balls, dropped into the sac, 
and allowed to hang out of the incision; in some, tents were 
introduced ; while in others, drainage tubes were employed. The 
time during which the escape of fluid continued, varied very much. 
Sometimes it ceased in a few weeks, while in other cases it con- 
tinued for a period varying from eight to twelve months. 

Although from the presentation of facts just made it is evident 
that the operation of incision is one attended by great dangers, it 
must not be forgotten that in a certain class of cases it may render 
valuable service. When, for example, the tumor is multilocular 
and firmly adherent, it may be resorted to with two good results : 
first, it enables the operator more perfectly than any other method 
to reach successive cysts ; and second, it offers a chance of per- 
manent cure, without removal of the sac, almost equal in pro- 
portion to two out of three. The emptying of one large cyst will 



554 OVARIAN TUMORS. 

be better accomplished by simple drainage, but in case a number 
of cysts exist, that plan will generally fail. 

Injection into the sac. — The insufficiency of simple tapping of 
ovarian sacs led Denman, 1 Bell, Hamilton, and others, to inject 
into them solutions of sulphate of zinc and other substances, but 
without effect. In 1846, 2 Dr. Alison, of Indiana, U. S., essayed 
the injection of tincture of iodine with a successful issue after 
repeated trials on the same patient. Although others in France 
and Germany employed the method after this time, it was not 
systematized and placed upon the footing of a recognized pro- 
cedure until it received the attention of M. Boinet, of Lyons. 
This practitioner, bringing a great deal of enthusiasm to the work, 
soon accumulated a large experience. 

He employs for the purpose iodine and iodide of potassium, 
in the following manner : — ■ 

R.— Tr. of iodine 100 parts. 

Iodide of potassium 4 parts. 
Water 100 parts.— M. 

From four to ten ounces of this solution are injected, allowed 
to remain for some minutes, and then removed. 

The injection is thus simply and perfectly accomplished. A 
trocar and canula being passed, the fluid is removed from the 
cyst. A flexible catheter is then passed through the canula, deep 
into the cyst, and by means of a hard rubber syringe the fluid 
is injected through this. After having been retained for ten or 
fifteen minutes it is allowed to escape, or may be drawn off by 
the syringe. The catheter is kept in position for some days or 
weeks, and through it a solution twice as strong in iodine is soon 
used. Then as the cyst lessens considerably, pure tincture is 
employed. Mr. I. B. Brown employs the pure tincture of the 
Edinburgh Dispensatory. 

Sometimes, as, for example, in a case published in the Syden- 
ham Society's Year-book for 1861, by Lowenhardt, the pain re- 
sulting from this procedure is excessive, and the shock to the 
nervous system so great as to destroy life. Boinet declares that 
so long as the injected fluid is confined to the sac, pain and ten- 
dency to collapse do not occur, they being due to its entrance 

1 Simpson, op. cit., p. 362. 2 Peaslee, Ovar. Tumors, p. 11. 



INJECTION" INTO THE SAC. 



555 



into the peritoneum. This view is sustained by Lowenhardt's 
case, in which a post-mortem examination was made, and re- 
vealed a " small amount" of iodine in the peritoneum. The 
reporter lays no stress upon this, and yet the symptoms of which 
the patient died were just those witnessed after passage of fluids 
through the Fallopian tubes. 

As to the statistics of the operation, it is difficult to speak 
positively. The following are probably the most reliable which 
have been published : — 



Author. 


No. of cases. 


Cures. 


Failures. 


Deaths. 


Douhtful. 


Boinet ..... 


45 


31 


5 


9 




Cazeaux 










62 


48 


11 


3 




Grunther 1 










158 


32 


61 


59 




Simpson 










40 or 50 (?) 


— 


— 


1 




Scanzoni 










4 


— 


— 


4 




West 2 










10 


3 


6 


1 




Tyler Smith 










12 


2 


9 


1 




Peaslee 










6 


1 


3 


1 


1 



A certain degree of doubt seems to attach to some of these 
statistics. Those of Prof. Simpson are evidently too loosely re- 
ported to be depended upon, and Courty reviews those of Boinet in 
the following words: "According to this honorable practitioner, 
they, the injections, produced a cure in three out of five cases, 
and always a remarkable improvement. It is to be regretted 
that these fortunate results have not been reproduced in such 
satisfactory proportions in the experience of the majority of phy- 
sicians who have had recourse to the same method." " At pre- 
sent," he continues, " the profession shows a strong tendency to 
abandon this treatment, the dangers of which are often mani- 
fested by fatal results." It is difficult, however, to regard this 
criticism as just, when we see so reliable an authority as Vel- 
-peau reporting, as he did in a discussion in the Academy of 
Medicine, one hundred and thirty cases, not operated upon by 
himself, as yielding sixty -four cures and thirty deaths. Even the 
statistics of Dr. West, whose extreme accuracy as an observer is 
well known, prove the fact that the operation of injection of 
iodine is not as dangerous as M. Courty appears to imagine. Dr. 



1 In six the results were not stated. 

2 In two of these cases one cyst was cured and another progressed. 



556 OVARIAN TUMORS. 

Peaslee draws from existing evidence the following conclusions : 
if restricted to patients previously tapped, which he regards as 
an important point, and to unilocular sacs, unattended by inflam- 
mation, and not containing a thick, tenacious fluid, the mortality 
would probably be one in ten, and the cures one in three. 

His method of selecting the cases applicable for this plan is 
the following : — 

1. Eeject all polycystic tum.ors, excepting the cases when we 
only expect to diminish for a longer or shorter time, a single one 
of the sacs. 

2. Reject all monocystic tumors also, whose contents are dense, 
viscid, and albuminous, as a general rule ; the exceptions present- 
ing themselves in some cases where ovariotomy is out of the 
question. 

3. Reject also all single sacs whose contents are made up in 
part of inflammatory products. 

4. There remains, then, for the iodine injection, only the 
simple sac, with clear, serous contents, and this should have been 
tapped once at least, previously, as a general rule. Adherence to 
this last precept also enables us to decide, before we determine 
to use the iodine, whether we have a single sac, or more — a very 
difficult thing to determine before tapping, in many cases. 

Even should a sac collapse under the injection of iodine, the 
practitioner must not be too sanguine as to the result, for, even 
after remaining in this state for years, they often refill, and re- 
quire a repetition of this operation or the performance of some 
other. 

Partial excision. — It has already been remarked that when an 
ovarian cyst is broken in consequence of any accident, and 
empties itself into the peritoneum, complete recovery may take 
place by absorption of the effused fluid, and collapse of the 
emptied cyst. Of seventy cases of this accident reported by Dr. 
Tilt, forty, over half, recovered. The operation which we are 
now describing has for its object an imitation of this patholo- 
gical result, and consists in opening the sac so that its contents 
may pour into the peritoneal cavity without escaping from it 
through the abdominal walls. It was first performed by Guerin 1 

1 Simpson, op. cit., p. 353. 



PARTIAL EXCISION. 557 

and Bainbridge, from a suggestion by Dr. Blundell, according to 
Prof. Simpson ; while Mr. Baker Brown ascribes it to Jefferson, 
"West, and Hargraves. 

The method is obnoxious to these objections : 1st, the large 
vessels ramifying upon the sac may be cut, and hemorrhage 
excited; 2d, a species of fluid may be evacuated, which will 
excite peritonitis ; 3d, the tumor may be multilocular, and only 
one cyst be evacuated. Its sphere is therefore limited to cases 
in which the character of the contained fluid is ascertained by 
tapping to be of a bland, unirritating nature, and free, or almost 
free from albumen, and in which a monocystic tumor is supposed 
to exist. If the case be one of a character favorable for this 
procedure, the risks of peritonitis, inflammation of the sac, and 
septicaemia from absorption of its putrefying contents, which 
often result from simple tapping, are avoided on the one hand, 
and those of ovariotomy on the other. It was very recently re- 
sorted to in this city with entire success, by Dr. W. L. Atlee, 
of Philadelphia, in the case of a very large cyst, the contents of 
which were found by chemical examination to be free from 
albumen. 

There are three methods in which it may be performed. If the 
monocystic character of the tumor and the innocuousness of its 
contents have been fully ascertained by previous tapping and 
physical examination, the cyst may be again emptied by a large 
quadrangular trocar, four-fifths of the contents drawn off, and the 
abdominal opening closed. Then each day a little fluid should 
be expressed from the tumor still remaining, by compression by 
the hands, in order to keep the wound in the sac from uniting. 
This is the method of Prof. Simpson. Under r the same circum- 
stances an incision of an inch in extent may be made down to the 
tumor, a portion of this seized with clawed forceps or tenacula 
and excised, and the outer wound united. 

Should any doubt exist as to the characters of the tumor and 
its contents, everything should be prepared for the operation 
of ovariotomy in case these be found adverse to partial excision. 
Then by an incision two or three inches long the surface of the 
cyst should be exposed, a large piece of this cut out, and the 
abdominal wound closed. In this way all large bloodvessels nun- 
be avoided, as sight and touch are brought to the operator's 



558 



0VAEI4N TUMORS 



aid, and a sufficient portion of the sac is removed to prevent 
reunion. 

Prof. Byford refers to a fact which in some cases must have an 
important bearing upon the success of this operation. It is that 
the contents of an ovarian cyst which are first evacuated may be 
clear and apparently bland, while that portion of fluid which 
comes forth last is thick, grumous, and acrid. 

Other methods which have been advised, in addition to those 
alluded to, are the creation of an abdominal issue by use of 
caustic potash, by Dr. Tilt ; ligation of the pedicle, by Dr. Tan- 
ner ; pressure after tapping, by Dr. Baker Brown; "aspiration" 
or suction, by M. Buys ; the seton ; electricity ; acupuncture ; and 
a number of others, a description of which is not deemed necessary 
in the present essay. 

In some cases, continuous pressure, after the plan of Dr. Brown, 
has effected not only amelioration but cure. The best method for 
accomplishing it is by the elastic apparatus of Bourjeaud, repre- 
sented by Fig. 209. 

Fig. 209. 




Bourjeaud's elastic compressor. (Wieland and Dubrisay.) 



following 



surgical 



Resume. — We have now considered the 
means for the cure of fluid ovarian tumors : — 

Tapping ; 
Drainage ; 
Incision ; 
Injection ; 
Partial excision. 
It is evident, upon consideration, that each of these possesses 
certain advantages and disadvantages. These have already been 



\ 



RESUME, 559 

spoken of; nevertheless it may not be useless to recapitulate those 
which are common to all the methods thus far treated of. 

1st. All of them are applicable chiefly to unilocular tumors, 
success attending their employment in multilocular cysts very 
rarely indeed. 

2d. Their employment is confined entirely to fluid tumors, so 
that if an error of diagnosis should have been committed, these 
operations cannot, as ovariotomy may, be turned to good account. 

3d. One of the greatest dangers attending all of them is peri- 
tonitis, which should be carefully guarded against by complete 
evacuation of the contents of the sac, washing it out with warm 
water, and strictly insisting upon the recumbent posture. 

4th. Two other great dangers are, inflammation of the cyst 
walls and absorption of the decomposed contents remaining within 
the sac, which is most surely prevented by the use of antiseptic 
injections repeated at short intervals, preceded by complete 
emptying of the cavity. 

5th. In monocystic and even in polycystic tumors which are 
bound down by false membranes of such strength as to render 
removal of the cyst impracticable, these procedures hold out the 
only hope for the cure of the patient. 



CHAPTER XLIII. 



OVARIOTOMY. 



Definition. — This term, derived from coapiov, "the ovary," and 
tfo/AAf, "incision," signifies simply the removal of the ovary by sur- 
gical procedure. 

History. — The history of the operation goes back only to a very 
recent date. It has become customary for those who have written 
upon it to cite ancient authors to prove that even as long ago as 
the time of the early Greeks the ovaries were often removed in 
the inferior animals as is done at our own time. The writings of 
Aristotle put this beyond question. It is even asserted that among 
the Lydians castration of the human female was practised in order 
to enable them to serve as eunuchs. In more recent periods, we 
are told by Wierus, that a Hungarian swineherd, incensed by the 
lasciviousness of his daughter, removed her ovaries, in hope of 
reformation, after the manner in which he was in the habit of 
spaying his swine. Towards the close of the eighteenth century 
both ovaries, which had descended into the inguinal canals, were 
removed by Dr. Percival Pott, of England. But all this, though 
interesting as a matter of physiology, has little to do with the 
operation of ovariotomy, according to the true signification of the 
term. In the one case a minute and healthy gland, which is 
sparsely supplied with blood, was removed from a healthy peri- 
toneal cavity. In the other a huge sac which is supplied by 
large bloodvessels, and has in many instances contracted adhesions 
with a diseased peritoneum, requires extirpation. 

Yelpeau 1 asserts that the idea of removing large ovarian cysts, 
even, is not new, since it was discussed in 1722 by Schlenker, in 
1731 by Willius, in 1751 by Peyer, and in 1752 by Targioni. 

1 Diet, de Med., torn. xxii. p. 590. 



* OVARIOTOMY — HISTORY. 561 

In 1758 Delaporte even went so far as formally to propose the 
operation to the Eoyal Academy of Surgery, and in 1781 Laumo- 
nier, of Eouen, through an error of diagnosis, absolutely removed 
the diseased ovary. Subsequent to this period, frequent sug- 
gestions of the operation as now performed were made, among 
others by John Hunter in 1787, and later still by Wm. Hunter. In 
1798 Chambon ventured to prophecy that it would in time become 
a recognized resource in surgery, and in 1808 1 Samuel d'Escher, 
a student of Montpellier, proposed a specific plan for its perform- 
ance based upon the teachings of one of his masters, M. Thumin. 

Thus, as we advance from more remote periods to the begin- 
ning of the nineteenth century, we find the minds of physicians 
being gradually prepared for the reception of ovariotomy as its 
consummation was step by step approached. But all which we 
find accomplished up to this time is the emission of ideas, pro- 
phecies, and propositions, and the performance of accidental ope- 
rations, or of those upon healthy ovaries. 

In 1809 2 the first real case of ovariotomy ever undertaken was 
successfully performed by Dr. Ephraim McDowell, of Kentucky. 
His first case was successful, the patient living twenty-five years 
afterwards. Subsequently he operated thirteen times, with eight 
favorable results. In 1821 Dr. Nathan Smith, of this country, ope- 
rated successfully. In 1823 Dr. Lizars endeavored to introduce the 
operation into Scotland, and operated four times, but his results 
were bad. In one case the tumor was uterine and was not re- 
moved, in one no tumor could be discovered after abdominal sec- 
tion, and one of the two cases upon which ovariotomy was per- 
formed died. 

Since this period, Atlee, Peaslee, Kimball, and Dunlap have 
been most influential in establishing the operation in America. 
In England, Dr. Charles Clay, in 1840, pressed it upon the notice 
of the profession, and he was soon ably sustained by Lane, Wells, 
Baker Brown, and many others, whose names have become famous 
in connection with it. 

1 Wieland and Dubrisay, op. cit. 

2 Dr. Baker Brown's historical sketch of this operation commences, " I do not 
pretend to give a history of the operation of ovariotomy." The necessity for this 
declaration will be fully appreciated when it is stated that nowhere in his notice 
is the name of McDowell, Atlee, or any other American surgeon to be found. 

36 



562 OVAEIOTOMY. 

In Germany the operation was performed in 1819 by Chrys- 
mar, and subsequently by Dieffenbach, Heyfelder, Kiwisch, Sie- 
bold, and Langenbeck. But the results in that country have 
been singularly unfortunate, so markedly bad, indeed, that Scan- 
zoni, writing in 1856, says, "We consider ovariotomy a surgical 
temerity * * * * It results from what precedes that we 
ought completely to reject ovariotomy, and that we will renounce 
the glory of having successfully performed such an operation, 
until facts come to demonstrate that it does not terminate as fre- 
quently by death as we now think." It is hardly just to quote 
such a passage, ten years after it was written, in regard to an 
operation which has so rapidly grown in favor as this. Whether 
the facts furnished by English and American ovariotomists have 
caused the eminent German Gynecologist to reverse his conclu- 
sion, as they have Drs. Charles West, Tyler Smith, Savage, Hall 
Davis, and many other candid searchers after truth, I am unable 
to say. Prof. Scanzoni's work was translated in this country by 
Dr. A. K. Gardner, in 1861, who annotated it, "with the approval 
of the author," and no renunciation is there made. 

Into France the operation was introduced, or as some French 1 
writers express it, "reintroduced," by Dr. Woyerkowski, in 1844. 
It was subsequently performed by Yaublegeard, in 1847, and later 
still by Nelaton, Maisonneuve, Jobert, Demarquay, and other 
surgeons of Paris. The results of these attempts, however, had 
the effect of casting discredit on the operation from which it is 
only now emerging, thanks to the writings of Jules Worms, 
Oilier, Labalbary, Yegas, and more especially those of Koeberle, 
of Strasbourg. When it is stated that all these writers have pub- 
lished since 1862, it will be appreciated how recent is the favor- 
able reception of the operation in France. 

M. Boinet has just read an essay 2 before the Academy of Medi- 
cine, strongly advocating it, and "reprobating the timidity of 
French surgeons who have so long recoiled before it." 

In conclusion, it may be said that the conception of the operation 
in all its steps is over an hundred years old, and is of European 
origin ; that for its accomplishment we are indebted to what M. 

1 French Trans, of Churchill. 

2 N. Y. Med. Record, July, 1867. 



VARIETIES — DANGERS. 563 

Piorry once styled, " une audace Americaine," which was sup- 
plied by Dr. McDowell; and that many of the important improve- 
ments which have since been introduced, we owe to Great Britain. 
Pre-eminently an Anglo- American procedure, it has, even at the 
present day, not assumed its legitimate place in France and Ger- 
many. 

Varieties. — There are no varieties of the operation, except as it 
is accomplished by the long or short abdominal incision. Incom- 
plete cases, or those in which only a portion of the sac is re- 
moved, have been grouped under the same head, but very im- 
properly so, for less than complete removal constitutes an entirely 
different operation, which has already been described as partial 
excision. 

Advantages. — The advantages of the operation are these: it 
enables us to remove solid and polycystic tumors which are cura- 
ble by no other method, and to extirpate those of unilocular form 
which have resisted all other procedures. Great as are the dangers 
of the operation, it often offers a better prospect for recovery than 
any of the other plans mentioned, and in case of their failure it 
always remains as a reasonable hope for the patient, whose life 
will probably terminate in three or four years, if art does not in- 
terfere. 

Dangers. — The dangers which attend it are numerous and grave. 
The following table, constructed by Dr. Peaslee out of the post- 
mortem evidence of 50 fatal cases, will exhibit them at a glance. 



Peritonitis . 


12 


Strangulation of intestine in 








wound .... 


1 


Septicaemia . 


9 


Diarrhoea .... 


1 


Shock or collapse 


7 


Erysipelas 


1 


Exhaustion . 


. 7 


Tetanus .... 


1 


Shock and Septicaemia 


. 1 


Ulceration through bladder 


1 


Hemorrhage 


. 1 


Unknown 


9 



It will be seen from this that peritonitis destroys one-quarter 
of all who die from the operation and septicaemia, or absorption 
of putrid material, one-sixth. After these causes follow those 
directly resulting from the depressing influence of the operation 
upon the nervous system. 

Dr. John Clay makes the following analysis of the causes of 
death in 150 fatal cases, reported in his tables. 



564 OVAKIOTOMY. 

Shock or collapse 25 

Hemorrhage 24 

Peritonitis 64 

Phlebitis 1 

Tetanus 2 

Intestinal affections ...... 6 

Abscess 3 

Chest diseases 4 

Congestion of brain 1 

Diabetes , 1 

Not stated 19 

150 

Here also peritonitis appears as the most frequently fatal sequel 
of the operation, then come shock or collapse, and hemorrhage. 
After these there are no causes which are especially operative. 

It may be stated as a fact, that peritonitis and septicaemia occur- 
ring after the operation, are not due to exposure of the peritoneum 
to air or to any special tendency of the vessels of the stump to 
absorption of putrid matters. It is, to say the least, extremely 
probable that both result from — 

1st. Putrefaction of blood and the contents of the sac left in 
the peritoneum, or oozing into it from the small vessels of broken 
adhesions. 

2d. Putrefaction of the stump beyond the ligature securing its 
vessels. 

3d. Phlebitis set up by ligation of the veins of the stump. 

4th. Pouring of pus into the peritoneum from incomplete 
closure of the peritoneal lips of the abdominal incision. 

5th. Irritation of the peritoneum by foreign substances (liga- 
tures), left within it. 

If these propositions are true, the indications suggesting them- 
selves for the avoidance of danger will be — 

1st. To leave no fluid susceptible of putrefaction in the perito- 
neum. 

2d. To prevent secondary hemorrhage by carefully checking 
all flow before the abdominal wound is closed; by ligatures, tor- 
sion, the actual cautery, and persulphate of iron. 

3d. To avoid collection of pus in the peritoneum by uniting 
the abdominal wound on both its cutaneous and peritoneal 
aspects. 

4th. To avoid as much as possible leaving foreign substances 



STATISTICS OF OVARIOTOMY. 565 

within the peritoneum, and to employ the most innocuous sub- 
stances as ligatures when these are necessary. 

Statistics of Ovariotomy. — The time has passed when in an essay 
upon this subject the question need be asked as to the propriety 
of recognizing ovariotomy as a legitimate resource in surgery. 
The operation has to-day not only the verbal indorsement of the 
first surgical talent of the world ; it has the more positive testi- 
mony of those resorting to it in dealing with cases requiring its 
aid. So lengthy is the list of eminent names giving it their 
sanction, and so thoroughly has the ground been investigated by 
recent writers, that I deem it unnecessary to examine it more 
minutely. But besides this the results and rapid spread of the 
operation in Great Britain and America may be pointed to in 
reply to such a question, results which are fully as favorable 
as those of other important capital operations. 1 "Take, for 
example, hernia. Sir A. Cooper records 36 deaths in 77 ope- 
rations ; and Dr. Inman 260 deaths in 545 cases. Or ligature of 
the large arteries, of which Mr. Phillips has collected 171 cases, of 
which 57 died ; Dr. Inman 199 cases of which 66 died. Of 40 
cases of the subclavian artery 18 proved fatal." 3 

An approximative idea of the rapidity with which it has been 
accepted, may be obtained by the statistics collected by different 
writers during the past ten years : — 

In 1856 Dr. Lyman 3 collected 212 cases. 

In 1860 Dr. J. Clay* " 425 " 

In 1864 Dr. Peaslee 5 raised the number to 787 " 

In presenting the statistics of the subject it is difficult to do so 
with perfect justice. The operation is a recently employed pro- 
cedure, and although simple in its details depends for success 
so much upon little, and at first sight apparently insignificant 
points, that the statistics of inexperienced operators cannot with 
justice be admitted. A proof of this is offered by a comparison 
of earlier and more recent results of the most eminent ovariotom- 
ists as given by Prof. Simpson : — 

1 Remarks by Mr. Erichsen in Lancet for 1862, p. 68S. 

2 Dr. Churchill's review of Dr. Lee on Ovarian and Uterine Diseases. 
8 Prize Essay, Mass. Med. Soc. 

4 Translation of Kiwisch on Ovaries. 

5 On Ovariotomy, trans. Acad. Med., N. Y. 



566 







OVARIOTOMY. 






Dr. 


C. Clay in 


his first 


20 operations 


lost 


L in 2g 




a < 


' second 


t( « 




L » 3J 




C< l 


' third 


a u 




L " 4 


Dr. 


S. Wells ' 


' first 


50 




I " 2 




< 


' second 


cc u 




I " 3 




' 


' third 


M 




L " 4 


Dr. 


Keith « 


' first 


20 




L « 3i 




K ( 


' second 


" 




L " 6| 


Dr. 


Atlee ' 


1 first 


101 




I " 2|f 




« < 


' folio win 


g78 


(i 


. « 8f 



Between the statistics collected in Germany and those in Great 
Britain and America, there is so marked a discrepancy that one 
cannot but agree with Dr. Atlee, 1 of Philadelphia, in this opinion: 
" The German mortality is excessive, and there must be a fault 
somewhere. Their great dread of making a free opening in the 
abdominal cavity, and their method of managing the pedicle, may 
have much to do with their want of success." Simon declares 
that out of sixty-one operations only twelve completely recovered ; 
and Scanzoni, 2 in giving his reasons for not accepting it, speaks 
of it as "a procedure by which Langenbeck has lost five patients 
out of six, and Kiwisch four out of five." 

As it is not my intention to present full statistics upon ovario- 
tomy, which would be out of place in a work of the character of 
this, but merely to give the practitioner certain facts which will 
enable him to decide in favor of, or against, the operation at the 
bedside, I shall content myself with stating the results obtained 
by operators who have become eminent in connection with it 
during the past ten or fifteen years. Of the following list, those 
who have operated in Europe are quoted on the authority of M. 
Courty ; those in America from personal testimony. The state- 
ment in all cases is brought up to May, 1866. 



Operator. 


Residence. 


No. of operations. 


Recovered. 


Died. 


I. B. Brown, 


London 


92 


59 


33 


Spencer Wells, 


« 


166 


112 


54 


Ch. Clay, 


Manchester 


117 


SO 


37 


Tyler Smith, 


London 


17 


14 


3 


Keith, 


Edinburgh 


40 


31 


9 


Koeberle, 


Strasbourg 


27 


18 


9 


Kimball, 


Lowell, U.S. 


72 


43 


29 


W. L. Atlee, 


Philadelphia 


162 


70 per cent. 


30 per cent. 


J. L. Atlee, 


Lancaster, Pa. 


27 


23 


4 


Peaslee, 


New York 


9 


7 


2 



Gardner's Notes to Scanzoni, p. 255. 



Op. cit., p. 471. 



INDICATIONS FOR OVARIOTOMY. 567 

Circumstances rendering a resort to the operation inadvisable. — 
Should an ovarian tumor grow very slowly, give no serious in- 
convenience to the patient, and not depreciate her general health, 
nor require tapping to secure her comfort, a resort to ovariotomy 
is not advisable. Though its results have been most gratifying, 
they are not sufficiently good to admit of interference in such a 
case as we are supposing. The following circumstances would 
strengthen this conclusion — 

Presence of much solid matter in the tumor ; 

Its existence after the menopause ; 

The patient being in robust health ; 

Eelief having been afforded by paracentesis ; 

Non-albuminous fluid having been withdrawn. 
The opposite of all these circumstances will call for it, unless 
one of the other operative procedures which have been mentioned 
be preferred. 

Conditions favorable to the operation. — Clearness and certainty of 
diagnosis ; 

Good constitutional condition ; 

Patient being hopeful and desirous of operation ; 

Unilocular character of cyst ; 

Absence of solid matter in its structure ; 

Abdominal walls not very thick ; 

Absence of adhesions and ascites ; 

Small amount of albumen in fluid of cyst. 
The possibility of error in diagnosis has been already suffici- 
ently dwelt upon. The importance of clearly understanding the 
nature of the tumor cannot be over-estimated. The operator 
should, by repeated, prolonged, and most careful examinations 
alone, and afterwards aided by others, endeavor to determine all 
the features of the case, not merely the fact that a tumor exists, 
but that it is ovarian and not uterine, that pregnancy does not 
exist with it, that it is not cancerous, that its contents are fluid, 
and that the fluid felt is all ovarian and none of it abdominal. 
In two cases I have, in company with a number of others who 
consulted with me, been greatly deceived. In one case, when 
upon the point of operating upon a large, multilocular tumor, the 
patient lying on the table, I discovered the existence of pregnancy 
in the fifth month. In another, which I supposed to be a largo 



568 



OVAEIOTOMY, 



ovarian tumor, "upon cutting through the abdominal walls, an im- 
mense amount of fluid escaped, leaving for removal an alveolar 
cyst of the ovary not larger than the adult head. When the 
reader is reminded that in a number of instances the most accom- 
plished diagnosticians have cut through the abdominal walls 
when no tumor whatever existed, this point will be sufficiently 
impressed. 

The constitution of the patient should be good, but not robust ; 
some, indeed, as, for example, Drs. Peaslee, Atlee, and Tyler 
Smith, prefer to wait for impairment of the health. The follow- 
ing table, constructed by Dr. J. Clay, of 229 cases in which the 
general health was ascertained, displays the remarkable fact that 
even emaciation does not produce a very unfavorable result : — 



Class of cases. 


Health good. 


Health 
impaired. 


Much 
emaciated. 


Complicated 


With other 
diseases. 


With 
pregnancy. 


Successful .... 
Unsuccessful . . . 


21 

21 


17 

25 


47 
46 


21 

27 


2 
2 


Total .... 


42 


42 


93 


48 


4 



The mental state of the patient has so marked an influence on 
the result that operators agree that a depressed and apprehensive 
mind generally produces an unfavorable issue. 

The greater the amount of solid matter in an ovarian tumor, 
the more favorable will be the prognosis as to rate of growth and 
the more unfavorable as to cure. 

The following is Dr. Clay's table in reference to the character 
of the tumor : — 



Class of cases. 


Monocystic. 


Polycystic. 


Solid. 


Small. 


Medium. 


Large. 


Successful . . . 
Unsuccessful . . . 


19 

25 


66 
106 


8 
13 


4 
3 


14 
17 


30 

48 


Total .... 


44 


172 


21 


7 


31 


78 



The greater the thickness of the abdominal walls the more 
extensive will be the surface which must unite to effect closure 
of the abdominal opening, and the greater the probability of sup- 
puration occurring between the lips of the wound and pus pour- 
ing into the peritoneum. 



UNFAVOKABLE CONDITIONS. 569 

The presence of adhesions greatly complicates the case, but as 
this can be determined only after abdominal section, its considera- 
tion will be postponed until that point in the description of the 
operation is reached. 

Dr. I. B. Brown first pointed out the importance of an abund- 
ance of albumen as a prognostic sign in ovarian cysts. " Believ- 
ing as I do," says he, " that the highly albuminous condition of 
the fluid exhausts the system in a similar way to that of albu- 
minuria from disease of the kidneys, I consider that it contra- 
indicates an operation as clearly as the latter disease. The nature 
of the contents may be readily discovered by withdrawing a little 
by an exploring needle." I give this quotation, not for the pur- 
pose of indorsing the view, but to show how strongly Dr. Brown 
feels in reference to the matter. The two states between which 
he draws a parallel are evidently different in this, that in one case 
the drain of albumen ceases with the operation, while in the other 
it continues unabated. In two of my own cases, the fluid removed 
by tapping after abdominal section was gelatinous, and yet the 
sac being removed the patients rapidly recovered without an 
unfavorable symptom. That an abundance of albumen gives an 
unfavorable, as its absence gives a favorable, prognosis, however, 
cannot be denied. 

Conditions unfavorable to the operation. — The following circum- 
stances, although unfavorable to the operation, do not contra- 
indicate it unless they exist in the most exaggerated degree : — 

Obscurity as to diagnosis ; 

Great constitutional impairment ; 

Gastric or intestinal disorder ; 

Depression of spirits ; 

Multilocular character of cyst ; 

Presence of solid matter in tumor ; 

Highly albuminous character of contents ; 

Presence of extensive and firm adhesions ; 

Complication with other diseases. 
Grounds upon which a choice of operative procedures should be 
based. — Before proceeding to describe the operation of ovariotomy, 
it will not be out of place to examine this question. 

Tapping is not a curative but a palliative operation, and need 
not detain us. 



570 OVARIOTOMY. 

Drainage. — When it is ascertained that a cyst is unilocular, and 
more particularly, when by explorative incision it is known to be 
adherent, this operation may be resorted to either by the vagina 
or abdomen. 

Injection is applicable to unilocular cysts rilled with clear and 
slightly albuminous fluid, or even to those containing pus or 
blood. It has not been found to produce good results in those 
containing thick, unctuous, and fatty matters. This plan may be 
combined with drainage. 

Incision. — This method of draining the cyst has its sphere in 
those unfortunate cases of multiple and polycystic sacs which, on 
account of firm adhesions, cannot be removed, and from their mul- 
tilocular character are not susceptible of treatment by drainage or 
injection. 

Partial Excision. — It is known that when a cyst containing a 
clear, straw-colored, non-albuminous fluid discharges itself into 
the peritoneum, recovery may take place, the effused fluid being 
eliminated and the sac contracting. Partial excision should be 
reserved for such cases and never employed in others, for' where 
the contents of the sac are tenacious and albuminous it is more 
fatal in its consequences than ovariotomy itself. Dr. Clay has 
collected 24 instances in which the operation was performed. 10 
patients recovered and 14 died, and of the 10 spoken of as 
recoveries only 7 were radically cared. 

Ovariotomy. — This operation is applicable to cases between those 
desperate ones of cystic disease susceptible of treatment only by 
incision, and those not susceptible of cure by injection or drain- 
age. It also offers the only hope in cases of composite and solid 
tumors. 

Preparation for the Operation. — We know that the septic endo- 
metritis, which is the starting point of those symptoms which 
grouped together constitute puerperal fever, is often excited by 
the miasm attaching to the medical attendant from an autopsy, a 
case of erysipelas, typhus fever, or hospital gangrene. Although 
the fact that these miasms will exert a similar baneful influence 
on the parts exposed in this operation is not proved, it is at least 
so probable that no operator should expose a patient to the test. 
It is true that in the one case a mucous membrane altered by 
pregnancy and parturition is involved, and in the other a serous 
sac ; nevertheless there is sufficient probability that evil might 



PREPARATION'S FOR THE OPERATION". 571 

accrue, to make us careful to avoid these sources of disease. Pre- 
vious to the operation the patient should be put upon a tonic 
course. Generous diet, iron, quinine, fresh air, cheerful sur-' 
roundings, and gentle exercise should, unless impracticable from 
some peculiarity of the case, be prescribed. Drs. Simpson and 
Atlee speak highly of the use of the persulphate of iron as a 
tonic. A visit to the country or some quiet watering place will 
prove of great advantage. Above all things, the mind of the 
patient should be made calm and cheerful, and every hope as to 
the result of the operation encouraged. After a candid state- 
ment of the chances of success has been rendered her as material 
upon which to base her determination to accept or reject the 
operation, no doubt ought thenceforth to be expressed as to the 
result by physician or friends. 

The operation should be performed in a locality where the air 
is pure and salubrious. Never in the wards of a crowded hospi- 
tal, and if a choice is offered, in the country rather than the city. 
The day selected should be clear, and neither very hot nor very 
cold. If the weather be cool, the temperature of the apartment 
should be kept at from seventy-eight to eighty, and the atmos- 
phere moistened by evaporation of water. A thoroughly experi- 
enced^ nurse should be in readiness to take charge of the patient. 

Two days before the operation a cathartic should be adminis- 
tered, in order to evacuate the bowels completely, and for three 
or four nights an opiate should be given at bedtime. This not 
only quiets the nervous system, but tests the patient's capability 
of tolerating that medicine. One hour before the operation, Dr. 
Atlee gives a dose of opium. The skin should be put into good 
condition by warm baths employed daily for a week or more, 
and its temperature kept equable during the operation by flannel 
drawers, as suggested by Dr. Brown. As the time for its com- 
mencement arrives, the bladder should be carefully evacuated, 
the patient anaesthetized by sulphuric ether, and laid upon her 
back upon a table of suitable height and strength, which is 
covered by folded counterpanes or blankets and placed before a 
window affording a good light. 

The operator will require at least four assistants, one to admin- 
ister the anaesthetic, one to stand opposite to him and aid in mani- 
pulating the tumor and abdominal wall, one to take charge of the 



572 OVARIOTOMY. 

instruments, and one to apply ligatures, the actual cautery, &c. 
A fifth, to be at command in case of need, will be always of advan- 
tage. Two or three pints of Peaslee's artificial serum, composed 
after the following formula, may be kept in readiness. 
R. — Sodii chloridi, giv. 

A.lbuminis ovi, ^vj. 

Aquae, Oiv. — M. 

The Operation. — Although this operation has of late years been 
so fully discussed, and so free an interchange of sentiment con- 
cerning it has been afforded, there is not one point connected 
with it upon which operators are agreed. The extent of incision, 
management of pedicle, closure of wound and the other steps 
which will be alluded to, are still subjects upon which great 
variety of opinion exists. I shall avoid discussions, and hoping 
to be pardoned for any appearance of dogmatism which may 
result from so doing, give such *a description as will, according 
to my view, best meet the requirements of practice. 
The steps of the operation are these : — 

1st. Incision ; 

2d. Examination for, and rupture of adhesions ; 

3d. Tapping; 

4th. Eemoval of the sac ; 

5th. Securing the pedicle ; 

6th. Cleansing the peritoneum ; 

7th. Closing abdominal wound. ► 

The incision is made by a bistoury held by the operator, who 
stands at the right side of the patient. This should pass directly 
through the linea alba, and should extend from a little above the 
symphysis pubis, upwards for two or three inches. Passing 
through the skin and adipose tissue, layer by layer, it is con- 
tinued until the operator sees the fibrous sheath of the recti 
muscles. Sometimes it is difficult to distinguish this from the 
peritoneum. If any doubt exists, it should not be incised until 
exposure to air and pressure by forceps, fingers, or sponges, have 
checked the venous flow occurring from the vessels exposed by 
the abdominal incision. Then the fibrous structure should be 
caught by a tenaculum, snipped with scissors, and a grooved 
director passed under it, upon which it may be slit. If this 
exposes the belly of one of the recti, it will be evident that the 
linea alba has not been struck by the incision. To reach it, a 



OPEKATION, 



573 



director should be pushed under the sheath across the muscle, 
and it will be arrested at the linea, where the incision may be 



Fi<?. 210. 




Position of operator. (Simpson.) 



made. All hemorrhage having now ceased, the parietal perito- 
neum should be lifted, snipped, and slit upon the director for the 
length of the incision. 

At this point a slight flow of straw-colored serum will usually 
take place, after which either the shining wall of the sac will be 
exposed to view, or, as will sometimes be the case, a thin layer 
of omentum will be found spread out over its surface. This 
should not be cut, but lifted like an apron and put aside. Some- 
times, in addition to omentum, a loop of intestine may be found 
over the anterior face of the tumor, as happened in one of Dr. 
Baker Brown's cases, where it would have been incised had the 
operator not slit the peritoneum upon a director with scissors. 

Dr. Brown has laid down, in reference to the abdominal section, 
this important rule: it should always be regarded originally as an 
explorative incision. If any condition contraindicating the re- 
moval of the sac be found to exist, it may then be closed without 
exposure of the patient to great danger, while if it be found advis- 
able to enlarge it to proceed, this may be done to any necessary 



574 OVARIOTOMY. 

extent. Dr. Wells has removed one sac by an incision of one inch 
and a half, and rarely resorts to one of over five inches. On the 
other hand, Dr. Clay, whose favorable statistics have been alluded 
to, prefers the long incision. The great dread which has always 
been entertained of cutting and exposing the peritoneum, lends a 
degree of fascination to the short incision. When, however, it is 
borne in mind that it is to putrefaction of retained fluids that 
peritonitis and septicaemia are chiefly due, this feeling will diminish 
in force, for it is evident that the smaller the opening the more 
difficult will it be to discover and close bleeding vessels, and to 
cleanse the abdominal cavity. 

The shining wall of the cyst, covered by visceral peritoneum, 
being now under the fingers and eyes of the operator, he has an 
opportunity of verifying his diagnosis by palpation. If it be 
positively settled that the tumor is purely fluid, it may be re- 
garded as ovarian. If it be composite or solid, before proceeding 
further its relations to the uterus should be determined by pass- 
ing the uterine sound into that organ. 

Examination for, and Rupture of Adhesions. — The hands being 
rapidly cleansed of blood which has collected on them during the 
incision, are dipped in a basin of tepid artificial serum, and two 
or three fingers are passed around the tumor between the parietal 
and visceral peritoneum. Should they meet with slight adhesions, 
these should be gently broken ; if none are reached, a large steel 
sound, previously dipped in warm serum, should be swept around 
the tumor as far as the pedicle. Special attention should be given 
to attachments to the liver, large intestines, uterus, and bladder, 
which are of far greater moment than those to the abdominal walls. 
This exploration, like that by the fingers, may be made to rupture 
slight adhesions, but those which are strong and well organized 
should be left for careful inspection and section after the incision 
has been prolonged. If such are found, the short incision of two 
to three inches should be prolonged upwards into the median in- 
cision of five to seven, or the long incision of ten to twelve, the 
judgment of the operator deciding as to which is needful. If by 
a short incision, and the means of exploration already mentioned, 
the absence of adhesions can be decided on, nothing more is neces- 
sary, for this step of the operation is complete ; but if it be found 
necessary, the incision should be prolonged, and the whole hand 



TAPPING. 575 

passed into the peritoneal cavity, in order that all the relations of 
the tumor may be clearly ascertained. 

The long incision having been made, as soon as all flow from 
the severed vessels has ceased, the operator should break all 
adhesions within reach by carefully peeling off their attachment 
to the tumor. Great care must be observed not to tear the cyst 
wall, lest escape of its contents or hemorrhage should occur into 
the peritoneum. In this way only moderate adhesions should be 
broken. Those of very firm and vascular character, should be 
dealt with after tapping. The patient should then, after the sug- 
gestion of Dr. Hutchinson, be turned on one side in order to cause 
the tumor to protrude through the incision, and fluid removed by 
tapping, to pour out of and not into the abdomen. 

Tapping. — If doubt exist as to the character of the contents of 
the tumor, a portion should now be drawn off with an exploring 
trocar, for if a clear, watery fluid containing no albumen be re- 
moved, the operation may be given up, and partial excision made 
to replace it ; while, on the other hand, a tumor supposed to be 
fluid may thus be proved to be solid or composite, without involv- 
ing flow of blood into the peritoneum. If this explorative punc- 
ture proves the tumor to contain, fluid, a large trocar like that of 
Spencer Wells, represented in Fig. 211, may be plunged in, fixed 

Fig. 211. 




Spencer Wells's trocar and canula. 

to the wall of the cyst by its wings, and the fluid allowed to pour 
out into an appropriate vessel through a caoutchouc tube at- 
tached at the mouth of the canula. 

While the fluid is pouring out, compression of the abdominal 
walls should be made against the tumor by an assistant, who 
places one hand on each side of the abdominal incision, and the 
sac kept from collapsing by strong tooth forceps made to grasp its 
lips. 



576 OVARIOTOMY. 

When the first sac is emptied, the canula should be removed 
and the index finger introduced in order to ascertain the existence 
of other cysts, endogenous, exogenous, or multiple. These should 
be tapped in a similar manner, an incision, if needed, being made 
in the cyst wall for the purpose of facilitating the process. All 
the large cysts being emptied, the operator should at once proceed 
to the removal of the sac. 

Removal of the Sac. — The sac being now drawn out by the 
tooth forceps, tenacula, or pincers, which have been fixed in it to 
prevent its collapse, is seized by the fingers of the operator or 
assistant, and gently drawn forth through the incision. If an 
adhesion which has resisted the manual efforts already made to 
rupture the attachments, hold it in the abdomen, this should be 
severed by detaching it from the cyst wall by the fingers, which will 
now reach it readily ; by the actual cautery, as suggested by Dr. 
Brown, if it be long enough to avoid cauterization of the abdomi- 
nal wall; by scissors, if a cutting instrument must be used; or by 
a small ecraseur, if it can be applied. No rule can be given as to 
the best method, for each case will require the plan specially 
adapted to its peculiar features. This maxim must be constantly 
borne in mind ; that plan is best which severs the attachment with- 
out injuring viscera or opening bloodvessels, for these are the two 
evils to be feared. If a flow of blood follows the severance of the 
adhesion, the vessel should be exposed, freely touched with per- 
sulphate of iron, or with the actual cautery so lightly as not to 
create a slough. 

By the means recommended, adhesions will generally be severed 
without the application of ligatures, but now and then this is neces- 
sary. If it be so, silver wire should be employed when practica- 
ble, instead of silk as less likely to induce inflammation. In some 
cases, however, the cyst adheres so strongly to some viscus that 
it cannot be separated. Under these circumstances a portion of 
the cyst wall should be cut out and allowed to remain upon the 
surface to which it so pertinaciously clings. M. Boinet 1 points 
out the propriety of removing the secreting surface of such a 
piece before leaving it. The tumor being freed from attachments 
is now drawn forth, and the pedicle seized in the fingers. 

1 N. Y. Med. Record, July 1, 1867. 



SECURING THE PEDICLE. 577 

Securing the Pedicle. — This, which constitutes one of the most 
important steps of the operation, is at times easily and satis- 
factorily accomplished, while at others it is invested with great 
difficulties. Unless the pedicle be excessively short, the sac may 
be drawn outside of the abdomen and this part grasped in the 
fingers. It may then be managed after one of the two following 
methods : — 

1st. It may be secured against hemorrhage and left between the 
lips and outside of the wound — 

a. By being transfixed by a double hemp ligature, one 
strand of which ties one half the stump and the other 
the other half, and fixed in wound by harelip pins. 
(Duffin.) 

b. By compression by a clamp. {Hutchinson.) 

c. By amputation by the ecraseur. (Atlee.) 

2d. It may be secured against hemorrhage and returned to the 
abdomen — 

d. By being secured by double ligature, as mentioned in 
a, returned, and ligatures allowed to hang out of lower 
angle of wound. (Clay.) 

e. By being tied, cut short, and returned to abdomen. 
(Tyler Smith.) 

f. By being temporarily constricted by a metallic wire. 
(Koeberle.) 

g. By severance by the actual cautery. (Baker Brown.) 
The prevention of hemorrhage by the ligature and clamp, a 

and b 1 are evidently identical in principle. The clamp, how- 
Fig. 212. 



A 




Spencer Wells's clamp. 

37 



578 OVARIOTOMY. 

ever, has tlie advantage of being simpler and more easily applied. 
The clamp most commonly nsed is that of Mr. "Wells, though 
many others are equally applicable. It is thus applied: the 
pedicle or neck of the tumor being held in the fingers, the 
clamp, Fig. 212, is adjusted so that one limb passes over one, 
and the other over the other side of it ; the two branches are 
then closely approximated so as to obliterate the vessels, and the 
sac is amputated above this by a bistoury. The clamp is then 
laid flat upon the abdomen and the incision closed. 

Another very effective clamp is that of Koeberle, represented 
in Fig. 216. The pedicle is included by it in the space repre- 
sented in black and constricted by action of the screw which is 
seen below it. 

When the ligature is employed, the sac is amputated and the 
stump placed between the lips of the wound and transfixed by 
harelip pins, or the sutures which close this part of the incision. 

Writing to Dr. A. K. Gardner, in 1860, Dr. Atlee says of these 
methods: "The great objection to the ligature is that it not only 
strangulates the peritoneum, but it leaves a sloughing stump, both 
of which are constant foci of irritation. By means of the ecraseur 
and the styptic, persulphate of iron, all ligatures are avoided." 
When amputation is thus performed, the stump may be fixed in 
the wound by pins or sutures. This method is peculiarly appli- 
cable to small and non- vascular pedicles, but all appear to fear 
to trust to the haemostatic powers of the ecraseur in other cases. 

The plan by which Dr. Clay returns the stump to the abdomen 
is employed in the following manner : a double ligature is passed 
through the centre of the pedicle and then cut so as to leave two 
ligatures in position. One half of the pedicle is then tied with one 
and one with the other. The sac is then amputated, the pedicle 
returned to the abdomen, and the ligatures allowed to pass out 
through the lower angle of the wound. This method possesses 
these advantages : it absolutely prevents hemorrhage, as the liga- 
ture always does, at the same time that it furnishes a vent for 
fluids which may afterwards accumulate in the peritoneum. Dr. 
Clay still employs it, and has obtained by it the flattering results 
of eighty cures in one hundred and seventeen operations. Few 
of the leading operators now follow the method ; those who desire 
to return the stump to the abdomen following with some modifi- 
cations the plan to which we now turn. 



SECURING THE PEDICLE, 



579 



Dr. Tyler Smith lias lately succeeded in rendering popular a 
method which was practised, according to Dr. Peaslee, as long ago 
as 1829 by Dr. Eogers, and afterwards by Dr. Billington, of this 
city. It consists in ligating the stump, cutting both ligature and 
pedicle as short as possible, returning them to the abdomen, and 
closing the abdominal incision. In this way Dr. Smith has ope- 
rated upon seventeen cases, and lost only three patients. Dr. 
Peaslee, 1 whose success as an ovariotomist has been remarkable, 
says of the method: "I now again refer to Dr. Tyler Smith's 
method of treating the pedicle as the best of all methods, and the 
one to which all others will, in my opinion, ere long give place." 

Koeberle, of Strasburg, employs the clamp when the pedicle 
is long, but when short, he compresses the stump by a species of 
constrictor which tightens a metallic wire that surrounds the 
pedicle. Fig. 213 will explain the mechanism of this instrument, 
which passes into the abdomen, the shank remaining in the wound. 

Fig. 213. 




Koeberle's constrictor. 

Baker Brown has of late practised amputation of the tumor by 
means of the actual cautery, and claims the astonishing results 
of twenty-nine cures in thirty-two operations. It is highly pro- 
bable that this method will accomplish a great improvement in 
the operation, and assume the position of a means of great value. 
Thus far it has not been extensively tried. 

In employing this method, Storer's clamp shield would an- 
swer an excellent purpose in protecting the parts. 

No rule can be given with reference to a choice between all 
these methods other than this : when the pedicle is long and 
slender it does not appear to matter very much which plan is 
selected, for all have yielded and are daily yielding, excellent 



Op. oit., p. S3. 



580 



OVARIOTOMY. 
Fig. 215. 




Storer's clamp shield. 

results ; but when it is very short the external does not promise 
nearly so well as the internal method of managing the stump. 

As to the special cases for applying the first and second plans 
the following suggestions (not rules) may be of service : — 

a. The clamp is applicable to long pedicles, requiring powerful 
ligation, and presenting a large amount of tissue for suppuration 
and decay. 

b. The ecraseur may be relied upon where the pedicle and 
vessels are small. 

c. Clay's method is eminently adapted to cases in which con- 
siderable suppuration is anticipated, and a vent for pus is required ; 
where, for example, many adhesions have been broken. 

d. Tyler Smith's method may be resorted to with confidence 
where the pedicle is small in volume, where no great disturbance 
of the peritoneum has occurred, and where we have no reason to 
anticipate suppuration. In my fourth case of ovariotomy I em- 
ployed it with complete success. 



REMOVAL OF SAC. 



581 



e. Koeberle's constrictor is applicable to just the same class of 
cases as the method of Dr. Clay, and for the same reasons. 

/. The severance of the stump by the actual cautery presents 
many advantages, and may be used in any case except where the 
vessels are very large. 

The statement just made as to its being immaterial whether 
the pedicle is returned or not, in ordinary cases, is based upon 
the comparative results of Wells, Brown, and others who do not 
return it, with those of Tyler Smith and other operators who do. 

The following analysis of a large number of cases is given with 
reference to this point by Dr. J. Clay : — 



Class of cases. 


Stated left 
within the 
abdomen. 


Inferred 
left within 

the 
abdomen. 


Kept with- 
out by 
various 
methods. 


Tied in 
two or 
more por- 
tions. 


Simply 
ligatured. 


Stitched in 
wound. 


Ecraseur 

used to 

divide it. 


Successful . 
Unsuccessful 


113 

58 


76 

97 


20 

25 


122 

57 


22 
26 


3 

3 


2 
1 


Total . . 


171 


173 


45 


179 


48 


6 


3 



The methods just enumerated are those by which hemorrhage 
from the vessels of the pedicle is prevented. The means by 
which the pedicle is sustained between the lips of the wound so 
as to keep its putrid extremity outside the body are these : it 
may be transfixed by one or two of the sutures or pins closing 
the abdominal wound; it may be held up by a transverse rod of 
steel, as is done by Koeberle; or it may be sustained by the 
clamp and two pins or sutures which do not transfix it but pass 
on each side in close contact with it. 

Obstacles to Removal of Sac which may he discovered as the Opera- 
tion proceeds. — There may be no pedicle, especially in cases of 
solid or semi-solid tumors, an indissoluble union existing with 
the body of the uterus. At other times the sac is in part bound 
down so that it cannot be removed, while part of it can be drawn 
out of the abdominal incision. When this is so, that portion 
which is drawn out should be removed, the lips of the part re- 
maining stitched carefully to the abdominal walls, and the incision 
closed except at its lower angle, which should be kept free by 
the insertion of lint, or a caoutchouc tube, b}^ which disinfecting 
fluids may be thrown in to prevent septicemia, as in ordinary 



582 OVARIOTOMY. 

drainage. This procedure is a modification of the operation of 
incision already alluded to. The omentum may be adherent to 
such an extent that its removal becomes necessary. When this 
involves considerable rupture of its bloodvessels, it may be cut 
off by the ecraseur and its bleeding extremity touched with per- 
sulphate of iron or the actual cautery ; or it may be amputated 
and brought outside the wound as is done in case of the pedicle. 

Before proceeding to the next step of the operation the remain- 
ing ovary should always be carefully examined as to the existence 
of disease, for if cystic degeneration exist, it ought at once to be 
removed. If very minute cysts exist, not larger than marbles, 
for example, they should be incised, but if large ones are found, 
secretion from the walls of which might cause sufficient flow into 
the peritoneum to excite peritonitis or septicaemia, they should 
be removed, for the great dangers of the operation have already 
been incurred, and it would be unwise to leave the seeds of another 
tumor to develop. 

Cleansing the Peritoneum. — The sac having been removed and 
hemorrhage checked, all fluids contained in the peritoneal cavity 
should be carefully removed by soft sponges squeezed out of warm 
water. Not only the intestines and abdominal walls, but espe- 
cially the pelvis should be completely and thoroughly cleansed. 
This is a point of great importance, and may decide the issue of 
the case. Every particle of fluid left will undergo decomposition, 
and expose to the great dangers of septicaemia and peritonitis. 
So momentous does this appear to some operators that Koeberle, 1 
after cleansing the peritoneum, always makes an opening through 
the recto-vaginal space to allow drainage of fluids which may 
collect, employing tubes of glass as drainage tubes. 

Closing the Wound. — This is accomplished by two sets of 
sutures, the deep and superficial. The first, composed of silver, 
are passed in the following manner : a thread of silver wire is 
passed at each of its extremities through a long and stout straight 
needle. One of the needles being grasped by strong needle- 
forceps is passed through the peritoneum of one abdominal flap 
near the edge of the incision and made to emerge through the 
skin one inch from the edge. Then the other needle is seized 

1 Courty. op. cit. 



CLOSING THE WOUND 



583 



and passed through in a similar manner. The suture is then 
secured by twisting. If it be desired to use quilled sutures, it can 
be accomplished by passing a doubled silver thread after the 
same method. These deep sutures, placed at the distance of half 
an inch apart, will bring the whole incision into contact from 
the peritoneum to the skin, and favor healing by first intention. 
Koeberle employs the quilled suture as represented at Fig. 216. 



Fig. 216. 




Closure of the abdominal wound. (Wieland and Dubrisay.) 

Besides these, superficial sutures or pins like those employed 
for harelip should be used, which pass through the skin and 



584 OVARIOTOMY. 

areolar tissue, but do not involve the peritoneum. Around them 
thread is wrapped in figure of 8. 

After this a long pledget of lint soaked in cold water should 
be applied over the surface of the wound, a bandage of flannel 
employed to keep this in place, a full dose of opium given, the 
patient put quietly to bed, covered warmly, and warmth applied 
to the feet. 

After- Treatment. — The patient should be kept quiet and free 
from pain by opium given, either by the mouth or rectum, so soon 
as she has rallied from the anaesthetic ; or, in case of great suffering, 
by the hypodermic method. Her nourishment should consist of 
milk, beef-tea, or some gruel with milk. Even these digestible- 
substances should be given in small amounts and with caution. 
Should there be a tendency to nausea and vomiting, pieces of ice 
may be held in the mouth or swallowed, and if these symptoms 
are so severe as to threaten rupture of the sutures, the hypodermic 
use of morphia should be resorted to. The patient should be 
placed in bed so that the trunk will be more elevated than the 
pelvis, in order to limit the locality of fluids in the peritoneum. 

The evils which are chiefly to be feared as sequels of the ope- 
ration are, within the first forty-eight hours, hemorrhage; from 
second to thirteenth day, peritonitis ; and from completion of 
operation to sixth day, nervous prostration. 1 

Septicaemia, being the result, first, of the decomposition, and 
second, of the absorption, of fluids in the peritoneum, is not likely 
to occur for a number of days. In Dr. Peaslee's cases it appeared 
in from four to twelve days, but it may take place in two or 
three weeks after the operation. 

The effect of the operation upon the nervous system should be 
guarded against by the means just enumerated as general rules of 
management, and by administration of stimulants, as wine, brandy 
or champagne, if the strength appears to be failing. In addition, 
the most complete quietude of mind and body should be afforded. 
All conversation and noise should be interdicted, the patient's 
hopefulness excited and fostered, and all muscular effort avoided. 
For four or five days the sigmoid catheter should remain in the 
bladder and the bowels be kept constipated by opium for ten days 

1 This calculation of periods is based upon one of Dr. Clay's tables constructed 
from one hundred and fifty cases of these accidents. 



AFTER-TREATMENT. 585 

or a fortnight. The avoidance of cathartics during this time is 
essential to safety, a neglect of this precaution often producing a 
fatal issue. About two years ago I was present at the removal of 
an immense cystic sarcoma by Dr. John O'Reilly, who made an 
incision extending from the xiphoid cartilage to the symphysis 
and after detaching many adhesions extirpated the mass. The 
patient did perfectly well for a week, and was in a fair way to 
recover. She was, however, very urgent that her bowels should 
be moved, and the doctor refusing to comply with her solicitations 
she took surreptitiously a full dose of bitartrate of potash. This 
acted as a hydragogue cathartic, but its action was not limited as 
it usually is. Diarrhoea, and soon dysentery, supervened and 
destroyed the patient's life. 

After the seventh or eighth day, tympanites may call for an 
alvine evacuation, which may be effected by an ordinary injection 
of soapsuds or an infusion of anise, chamomile, or fennel. 

Should hemorrhage be ascertained to be taking place, all dress- 
ing should be at once removed, and the stump, if out of the abdo- 
men, securely ligated or touched with the actual cautery. If it 
has been returned to the abdominal cavity, there is but one course 
available, that is, opening the wound, ligating the bleeding vessel, 
and cleansing the peritoneal cavity. Such a necessity is very 
unfortunate, yet this course holds out the only prospect of success. 

Peritonitis, which proves the cause of death in about one-quarter 
of all who die from this operation, is best avoided by leaving few 
or no ligatures in the cavity, by removal of all putrefactive 
matters, and by keeping the abdominal viscera at rest by prevent- 
ing vesical and rectal functions and applying a bandage. Should 
it occur in spite of these preventive means, it should be treated 
by full doses of opium, and if the patient's strength will bear it, 
the application of leeches and fomentations over the hypogastrium. 
Koeberle is in the habit of applying a bladder of ice on each side 
of the incision for a number of days after the operation, for the 
prevention of hemorrhage and peritonitis, but this plan is not 
followed by English or American operators. 

Septicaemia, which is, next to peritonitis, the most frequent 
cause of death, is, when once fully established, an almost hopeless 
state. It is ushered in by dizziness, excessive muscular prostra- 
tion, anorexia, great pallor, small, rapid, and very weak pulse, 



586 OVARIOTOMY. 

sometimes a low delirium, dry tongue, and a sweetish odor of the 
breath. It is probably this condition which is so often alluded 
to as a "typhoid state" after operations, and one cannot 'but sus- 
pect that many, if not most, of those cases quoted in Dr. Clay's 
tables as shock or collapse, occurring as late as the fifth, sixth, 
seventh, and tenth days, were really instances of this affection. 
In one of my fatal cases, already alluded to as alveolar cancer, the 
patient was doing quite well on the evening of the seventh day. 
On the morning of the eighth I was struck by her wild, maniacal 
expression and cadaverous countenance. Upon examination I 
found all the symptoms of septicaemia present, and she very soon 
succumbed to them. 

The gravity of this sequel has rendered all operators anxious to 
possess the means to avoid or remedy it. Most of the methods of 
avoidance have been already stated, the importance of the subject 
will, however, excuse my again referring to them as — 

1st. Completely cleansing the peritoneum; 

2d. Checking all hemorrhage before closing the abdominal 
wound ; 

3d. Establishing drainage through Douglas's cul-de-sac, should 
septicaemia appear imminent ; 

4th. Establishing drainage at lower angle of the wound ; 

5th. Mummifying the stump by persulphate of iron. 

To secure ready escape of fluids from the peritoneal cavity, 
Koeberle adopts two methods. The first consists in opening 
through the recto-vaginal space into the peritoneum, and leaving 
in the opening a glass drainage tube. The second, which is 
adopted when he returns the stump to the cavity constricted by 
the garotte, consists in introducing, down to the pedicle, a "dilator 
composed of two branches of lead, each of which is formed of two 
parts, one horizontal, destined to be applied on the skin, the other 
perpendicular, in the form of a gutter with a concavity within. 
These two valves, introduced separately into the wound, are kept 
apart by two transverse rods arranged upon a very simple plan." 1 
He highly esteems the use oF this instrument for drainage, which 
is kept in place after an operation until all discharge from the 
pelvis ceases. 

Drainage from the cavity is likewise effected by Dr. Clay's 

1 Wieland and Dubrisay, op. cit. 



■MHH 



AFTER-TREATMENT. 587 

method, and by introduction of tubes of caoutchouc through the 
lower angle of the wound. 

Koeberle adopts the plan of mummification of the pedicle of 
the sac, and the omentum, if he has had to cut this off, by free 
application of strong solution of persulphate of iron, believing 
that this prevents putrefaction and absorption. These are pre- 
ventive means. When the accident is at hand and its symptoms 
recognized, one of them has likewise been used as a curative 
measure by Keith, of Edinburgh. M. Courty thus reports it : 
after the clamp had been removed, peritonitis with effusion of 
fluid set in. On the sixteenth day after the operation a puncture 
was made through the recto- vaginal cul-de-sac, and a fetid fluid 
poured away with relief to the symptoms. In this case the ope- 
ration was resorted to for prevention of peritonitis. Upon stronger 
grounds it could be employed for septicaemia. 

The most valuable suggestion with reference to this matter has 
emanated from Dr. Peaslee, who has unquestionably placed at the 
disposal of the ovariotomist a method which robs the operation 
of much of its danger. It consists in washing out the peritoneum 
with disinfectants, and I cannot do better than describe it in his 
own words. " I first injected a solution of chloride of sodium (3j 
to Oj), into the peritoneal cavity of a patient much prostrated by 
septicaemia, in February, 1855. I began with one quart of the 
solution, and then drew out the same amount of fluid with the 
syringe ; though I soon found I could inject that or a larger 
amount, even two quarts, through a flexible bougie, and then 
changing the position so as to bring the free extremity to a lower 
level than the one in the peritoneal cavity, convert it at once into 
a siphon through which all the fluid would freely flow out. The 
immediate relief from the first injection was very striking; the diz- 
ziness and stupor at once disappearing, though to return again in 
from eight to twelve hours. I repeated the operation twice daily, 
and then once daily for a week, when the returned fluid no longer 
presented any odor of decomposition. When the fluid was un- 
usually fetid, I used a solution of the liquor sodae chlorinatae 
(3ij to Oj). The patient recovered rapidly from the time when 
the fetor of the fluid was overcome." 

"In September, 1862, I again resorted to the same practice in 
a second case of septicaemia after ovariotomy. " * * * * 



588 OVAEIOTOMY. 

11 A third case of septicaemia, produced by blood oozing from 
the omental vessels after ovariotomy, occurred in my practice in 
September, 1863. The symptoms appeared in this case on the 
fourth day, and the injections were commenced on the seventh. 
The same kinds were used as in the preceding case, the solution 
of liquor sodse chlorinatas, even 3j to liv of water sometimes, 
and it was found necessary to use them three times daily for 
twenty days, to keep the patient from sinking ; then twice daily 
for twenty -one days, and once daily for thirty- three days more ; 
making one hundred and thirty-five injections in all, in seventy- 
eight days. I found it better to inject a large quantity rapidly, 
and let it flow away immediately, usually injecting as much as 
the cavity would receive (one to two quarts at first). For the 
encouragement of others who may resort to this treatment, I should 
also add that it was persevered in, in the second case for four 
weeks, and in the third for three weeks, before any amendment 
in the character of the decomposed fluid could be perceived." A 
recognition of the importance of the principle demonstrated by 
these cases has induced me to give them full space. 

It would be at once simple and effectual to combine the cura- 
tive treatment of Peaslee 1 with the preventive measures of Keith 
and Koeberle. Probably an excellent disinfectant would be 
found in carbolic acid greatly diluted. 

As to the time at which the sutures are to be removed no fixed 
rule can be given, for it will depend upon the rapidity and per- 
fectness of union. Should union by first intention occur, some of 
them may be removed on, from the fifth to the seventh day. But 
great care should always be observed, and only those at points 
where the union is strong should be withdrawn. After with- 
drawal the lips should be firmly approximated by adhesive plaster. 
The clamp, if employed, or the ligature, if passed out through the 
wound, should be removed when they lose their hold by reason of 
sloughing and drop away. No traction should be applied to them. 

The patient should be cautioned about rising too early after 
convalescence ; and even after she is able to go about she should 
be very careful not to make any violent efforts. 

1 Peaslee introduced a tube (as Keith afterwards did), at the time of the ope- 
ration in the first case, still septiczemia occurred. 



CHAPTEK XLIV. 
fluid ovakian tumoes — continued. 

Cysts of the Broad Ligaments. 

Definition and Varieties. — It was stated in the first chapter de- 
voted to ovarian tumors that they all belonged to three classes — 
fluid, composite, and solid; and that the fluid ovarian tumors 
were of these varieties, hydatid cysts, ovarian cysts, and cysts of 
the broad ligaments. The first two of these varieties have been 
already investigated ; we come now to consider the last. Cysts 
contained in the broad ligaments are really not ovarian tumors, 
and classing them thus might with some reason be styled a mis- 
nomer. But clinically we have no means of distinguishing them, 
so that, while in a work on pathological anatomy a strict classi- 
fication would be proper, it would here only give an appearance 
of accuracy which would prove unreliable and delusive at the 
bedside. 

For the pathologist, all tumors, filled with fluid and existing 
over the site of the ovaries, are susceptible of absolute classifica- 
tion, for in his studies he cuts through the abdominal walls, and 
by sight and immediate touch learns the characters and relations 
of the morbid growths. But with the practical physician the case 
is different. For him, deprived as he is of the pathologist's 
means of observation, as a general rule, fluid tumors existing over 
the site of the ovaries are ovarian tumors until explorative in- 
cision teaches him otherwise. 

There are three forms of cyst which are found in the broad 
ligaments, that is, between the folds of peritoneum making up 
those ligaments : — 

Tubal dropsy ; 

Wolffian cysts ; 

Areolar cysts. 



590 OVARIAN TUMORS. 

Tubal Dropsy. — This condition, which is described under the 
names of hydrops tubas and hydrosalpinx, consists in the dis- 
tension of the Fallopian tubes by muco-serous fluid. It arises in 
this manner : some influence, for example, acute or chronic sal- 
pingitis, pelvic peritonitis or cellulitis, occludes both extremities 
of the tube. The inflammation of the mucous membrane of the 
tube creating a muco-serous fluid, the canal is distended by this, 
generally irregularly, to the size of the finger or small intestine. 
Thus far the affection does not concern our present investigation, 
for there is no probability that such a growth would resemble 
ovarian tumor so closely as to lead to an error in diagnosis. As 
this distension goes on, the mucous lining of the tube takes on the 
physical and physiological characters of a serous membrane, and 
secretes plentifully a serous, straw-colored, and slightly flocculent 
fluid. At times the distension of the walls of the tube proceeds 
so far that the fluctuating tumor which results gives all the phy- 
sical signs of ovarian dropsy. 

The testimony of authorities is almost unanimous that between 
this condition and ovarian dropsy there are no means of diagnosis. 
M. Aran sounds the key-note to the general belief when he declares 
that, 1 " the tube distended by liquid, I am perfectly assured, does 
not give a sufficiently clear sensation to allow us to diagnosticate 
its existence." Prof. Simpson, however, assumes a different posi- 

Fig. 217. 




Tubal dropsy. (Hooper.) 

tion. 2 He declares that, although " in practice this form of tumor 
is usually altogether overlooked or is mistaken for some other 

1 Op. tit., p. 633. 2 Op. cit., p. 432. 



M 



WOLFFIAN CYSTS. 591 

kind of tumor," it is really diagnosticable by the following means: 
11 1st, its free and independent mobility ; 2d, its elongated form ; 
and 3d, its wavy outline." Let any one examine the shape of a 
large tubal dropsy, like that represented at Fig. 217, for instance, 
and he will see that both the shape and wavy outline will fail him. 
When it is remembered that the affection frequently results from 
pelvic peritonitis, the freedom of motion will evidently be often 
delusive. "The diseased tube," 1 says Courty, "is rarely free and 
without alteration at its periphery : generally it bears signs of old 
inflammation, which is adhesive, and this fixes it to the neighbor- 
ing parts." I have met with the affection four or five times in 
autopsies, and this statement has always been sustained. 

The means of diagnosis just mentioned would be applicable to 
slight tubal distension, which is rarely productive of symptoms 
calling for examination. Few instances of diagnosis are on record, 
and even in cases where tapping has been supposed to substantiate 
it, it is by no means sure that such a disease existed. Prof. Simp- 
son reports but one case in his extensive experience in which he 
was able to come to a conclusion. He denies the possibility of 
great enlargement of these tumors, declaring that they rarely 
grow larger than a foetal head, and that we may justly be allowed 
to be skeptical as to cases reported as being much larger. Dr. 
Arthur Farre, 2 however, willingly admits the well-known cases of 
Bonnet and De Haen; the first of which contained thirteen pounds 
of fluid and the second thirty -two pounds. Scanzoni circum- 
stantially reports an instance in which the sac attained the size of 
the head of a child of ten years of age. 

Wolffian Cysts. — Within the external margin of the broad liga- 
ment where the two walls of the peritoneum pass from the fimbriae 
of the tubes to the ovaries, exists the body of Kosenmuller, par- 
ovarium, or Wolffian body, to which allusion has already been 
made as consisting of a number of little tortuous cords, some of 
which are perforated by canals. The slight secretion occurring 
from the walls of these tubes sometimes becomes greatly increased, 
and the containing walls becoming proportionately distended, a 
tumor is created. These cysts rarely attain a size greater than 
that of a large orange, and their distension generally stops short 
even of those dimensions. 

1 Op. cits, p. 987. 2 Supplement Cjc. Anat. and Phys., p. 619. 



592 OVARIAN TUMORS. 

Numerous instances of this form of tumor are reported by 
authors. Dr. Bright, in his work on Abdominal Tumors, delineates 
two striking examples, and in Mr. Spencer Wells's recent work, 
an instance is mentioned where the tumor was observed close to 
the uterus and was incised and emptied. 1 It is curious to ob- 
serve how uniformly in describing them they are likened to an 
orange. 

Areolar Cysts. — Cystic degeneration is much more likely to 
occur in those organs which have, as component parts of their 
structure, minute cavities lined by epithelium. Thus, the kidneys 
and ovaries are peculiarly liable to be affected in this way. But 
this kind of degeneration is by no means limited to such structures. 
It may occur in areolar tissue anywhere, and those organs, which, 
like the thyroid and mammary glands, are prone to production of 
new growths having areolar tissue as their basis, are likewise 
especially liable to it. 

It is believed by pathologists, 2 that under these circumstances 
the cyst is merely an expansion of the areolae of the areolar 
tissue. In various parts of the abdominal cavity such cysts are 
found under the peritoneum and classed, by Dr. Graily Hewitt, 
under the head of subperitoneal cysts. Mr. Safford Lee reports 
one case of a tumor which filled the abdomen, after having lasted 
for twenty-five years, and destroyed life. On post-mortem inspec- 
tion a large cyst was found behind the peritoneum, which had 
originated under the pancreas. He reports another which began 
on the right side of the abdomen, was tapped forty-eight times, 
and was found by autopsy to be omental. 

Throughout the literature of the subject of ovarian tumors, 
allusions, generally very obscure, will be frequently found to a 
kind of cyst, not ovarian and yet not "Wolffian, which are occa- 
sionally met with in the broad ligaments. As no special name 
has been applied to them I have ventured to style them areolar 
cysts, which appellation designates them as different in origin from 
the other two forms, and points to their relation to the areolar 
tissue. Two instances of such cysts are mentioned by Mr. Spencer 
Wells, one in Case XCIII. and the other in Case CXI. The latter 
is thus minutely described by Dr. Eitchie, who examined it : 

i Case XXX. 2 Wells, op. cit., p. 84. 



AREOLAE CYSTS. 593 

" Between the folds of peritoneum, which connected this with the 
tumor, appeared a little, clear vesicle, one fourth of an inch in 
diameter. It moved freely between the folds, and, having no 
apparent connection, could, by careful manipulation, be pressed 
from one part by the broad ligament to another. * * * The 
Wolffian body surrounded it; but the most careful dissection 
failed to show that it was connected with it, or that the cyst was, 
as might have been supposed, a dilatation of one of the tubules of 
that body." Dr. Eitchie was at a loss to account for the cyst, and 
suggests the possibility of its being a partially developed ovum. 

The other case was examined by Dr. Wilson Fox. It was a 
large cyst, about twice the size of the adult head. The ovary 
was healthy and not connected with the cyst. 

Scanzoni commences his article upon " Cysts formed between 
the folds of the broad ligament," thus: "Cysts are sometimes 
formed by a collection of liquid in the canals of the organ of 
Rosenmuller ; sometimes they are completely independent." 

I know of no other pathological proof, such as that afforded by 
the evidence taken from the work of Mr. Wells, that these cysts 
ever assume very large dimensions. The largest with the record 
of which I have met is that described by Dr. Fox, which was twice 
the size of a man's head. Nevertheless, it appears to me that, 
from the clinical evidence before us, we may assume that they 
sometimes become very voluminous. Dr. Peaslee tells me thai- 
he has met with several large ovarian cysts filled with clear, non- 
albuminous fluid, which were cured by tapping. This would 
probably not have been the case had they been developed in the 
proper tissue of the ovaries. He states, likewise, that in conver- 
sation he understood Mr. Spencer Wells that he had had the same 
experience. 

Mr. Baker Brown accounts for many if not most of the cures 
of ovarian cysts effected by one tapping upon this supposition, 
and the confidence of Dr. Washington L. Atlee in the belief may 
be judged of by the following instance. About four months ago 
I saw Dr. Atlee cut down upon a sac which held a number of 
gallons of fluid, tap it by an exploring trocar, and await the 
chemical test of the liquid drawn off. While this was being- 
made, he stated to the large concourse- of physicians present, thai 
should the fluid prove non- albuminous, he would view the cyst 
33 



59-i OVARIAN TUMORS. 

as one developed in the broad ligament, and not in the ovary; 
and instead of performing ovariotomy, he would then cut out 
only a small portion of the cyst wall in order to secure the dis- 
charge of its contents into the peritoneum, and close the abdomi- 
nal wound. The fluid was found clear and non-albuminous, when 
the operator did what has been just mentioned, and the patient 
rapidly recovered. In a communication upon this subject which 
I have received from his brother, Dr. John L. Atlee, the follow- 
ing views are expressed concerning these growths : — 

" It is very difficult, previous to tapping, to distinguish cysts 
arising from the broad ligament from true ovarian cysts. The 
former are invariably, in my experience, unilocular, and do 
not displace the uterus to the same extent as the ovarian, although 
in these latter there is sometimes but little displacement. The 
cyst wall is thinner, and the impulse on palpation is more sensi- 
bly felt. The absence of albumen in the fluid removed, its re- 
semblance to ascitic fluid, its translucency, and slightly purplish 
tint when exposed to the sun's rays, are very strong indications 
that the cyst is peritoneal. These cases, of which I have had six 
or seven, perhaps more, get well by tapping, alterative treatment 
and counter-irritation, with pressure. They sometimes burst 
from external violence, and the fluid is absorbed, and are errone- 
ously called spontaneous cures of ovarian cysts. It is in these 
cases, as in hydrocele, that iodine injections have done good ; in 
true ovarian cysts, in my opinion, seldom or never." 

Prognosis. — The prognosis of cysts of the broad ligament is, if 
their character be recognized after explorative incision, very 
favorable. It is not a rare occurrence for them to undergo spon- 
taneous cure, the cyst undergoing rupture from violence, and dis- 
charging into the peritoneum. 

Treatment. — No medical treatment has any efficacy. The 
surgical treatment consists in tapping by the vagina or abdomen, 
drainage, injection of iodine, and partial excision, so as to allow 
escape of the contents of the cyst into the peritoneum. The 
method proposed by Prof. Simpson, of tapping, closing the abdo- 
minal puncture and daily pressing fluid from the tumor into the 
peritoneum, would likewise be very appropriate. In no case 
would ovariotomy be necessary. 

This completes the subject of fluid ovarian tumors. 



SOLID TUMORS OF THE OVARY. 595 

SOLID TUMORS OF THE OVARY. 

This class comprises those ovarian tumors, the structure of 
which is entirely solid — no cysts or other collections of fluid 
matter entering into their composition as a characteristic feature. 

Varieties. — The following list represents the varieties of this 
form of disease : — 

Histoid tumors. 1 

Dermoid; 
Pileous ; 
Adipose. 

Fibrous tumors. 

Cancerous tumors. 

Histoid Tumors. — Tumors containing fat, hair, teeth, bones, skin, 
in fact all the harder textures of the body, are not unfrequently 
found in the ovaries. For these, from the close resemblance of 
their contents to the normal texture of the economy, the name of 
histoid tumors (lato^ "organic texture," and ftSo J} "like,") is ap- 
propriate. 

It was formerly supposed that these developments were always 
dependent upon conception, the product of which, instead of 
passing into the Fallopian tubes, had been retained and under- 
gone increase in the ovaries. But this view is fully contra- 
dicted by the fact that such tumors have been frequently 
discovered in other organs than the ovaries, in undeveloped 
females, and even in males. Cruveilhier accounts for them upon 
two hypotheses ; 1st, by ovarian pregnancy, followed by death 
of the foetus and proliferation from the skin, which thus becomes 
analogous to the blastodermic membrane of the impregnated 
ovum; 2d, by what the French style, "inclusion parasitaire," or, 
as we would term it, foetal intussusception. This consists in 
the following occurrence : as a foetus develops, a fructified ovum 
becomes enveloped in some part of its structure. The more 
advanced ovum goes on growing, and in time makes the future 
being. The smaller one also undergoes development, but, being- 
placed under unfavorable circumstances, soon ceases to advance 
according to fixed laws, and its tegumentary envelope produces 

1 I am forced to create this term, from the fact that no name exists for this family 
of tumors. 



596 OVARIAN TUMORS. 

some of the textures of the body. It is manifest that the first 
of these hypotheses is tenable only after conception has once oc- 
curred ; the second is' so without it. 

M. Pigne has analyzed eighteen cases with reference to the 
period of life at which they were found, with the following 
results : — 

5 existed in virgins under twelve years ; 

6 " " children from six months to two years ; 
4 " " the female foetus at term ; 

3 " " foetuses cast off at eighth month. 

Both the theories here advanced in explanation of this singular 
phenomenon are highly unsatisfactory. Opposed to the first are 
the following considerations : there is never in the tumor any 
trace of secundines ; they occur in undeveloped females and 
males ; and they exist in other parts of the body than the ovaries. 

Against the second view appear these facts : such tumors are 
more common in the ovaries than in any other part, and only a 
portion and not all of the tissues of the body are represented. 

To meet the want felt for an explanation, Lebert has advanced 
the theory that from the elements present, spontaneous generation 
of a portion of skin occurs, and this being given, we have, as Dr. 
Parre expresses it, "the basis out of which many of these pro- 
ducts spring." 

Histoid tumors vary in size from a hen's -egg to that of the 
adult head, but very rarely grow larger. They are hard and 
generally globular. One ovary is usually affected, and by only 
one tumor ; but instances are on record where a single ovary con- 
tained a large number. They usually consist of fat, long hairs, 
teeth, skin, and traces of bone intermixed. The teeth are usually 
imbedded in the cyst wall or attached to pieces of bone, and are 
sometimes very numerous. Schnabel 1 records a case in which 
they exceeded one hundred in number, and Ploucquet 2 one in 
which they amounted to three hundred. 

When the predominating element of the mass is hair, these 
tumors are called pileous or piliferous ; when fatty matter, adi- 
pose ; and when skin, dermoid cysts. 

Histories of such cases are so rare that I transfer the following 
from Prof. Kiwisch's work : "A girl, seventeen years of age, was 

Kiwisch, op. cit. 2 Becquerel, op. cit. 



SOLID TUMORS OF THE OVARY. 597 

attacked with a swelling of the left ovary which, after twenty -one 
years, measured four ells in circumference, and reached below the 
knee. After her death, which took place in her thirty-eighth 
year, it was found that the sac alone of the ovary weighed four- 
teen pounds, and contained forty pounds of a thick, adipose, 
honey-like mass, which was mixed with many hairs of different 
lengths, among which curls were found two inches long, and as 
thick as a thumb, very like elf locks ; the internal surface of the 
sac was set with short hairs. There were also found eight bony 
concretions of irregular shape, one of which was seven and another 
ten inches long, and about two inches broad; the form of one of 
these bones was polygonal, and set with six molar teeth and one 
incisor, and nine separate bones were present besides. The teeth 
had the size, perfectness, and firmness which they generally have 
in a girl twenty years of age." 

Histoid tumors are harmless, except in so far as they mechani- 
cally interfere with the surrounding parts in different movements 
of the body. Yery often they are discovered by accident only. 
Physical exploration reveals a hard, round mass, painless upon 
touch, and unless its size prevents it, perfectly movable. 

Although in themselves innocuous, and not likely to increase 
rapidly or to attain any great development, they sometimes set 
up very serious and even fatal disturbance by one of three 
methods : by creating suppuration and abscess on account of the 
irritation kept up by a foreign mass; by perforation and dis- 
charge into the peritoneum ; or by the cyst which contains the 
histoid elements secreting fluid and changing its character to that 
of a fluid tumor. 

No treatment is required, a fortunate circumstance, since none 
would be at all effectual except extirpation. This would be 
eminently inadmissible, since there are not sufficient dangers 
attendant upon the tumor to warrant a resort to so hazardous a 
procedure. Dr. Graily Hewitt 1 refers to an instance in which 
Dr. Alexander Simpson injected one with iodine, but says that 
the result was not such as to encourage a repetition of the plan 
in future. 

Fibrous Tumors. — This form of tumor is rarely met with in the 

1 Op. oit., p. 577. 



598 OVAEIAN TUMOES. 

ovary, and never attains a very great size. Kiwisch reports two 
cases, one the size of a child's and the other the size of a small adult 
head. When it is borne in mind that uterine fibroids are strictly 
homologous with the organ from which they spring, and that 
they absolutely contain as structural components the peculiar 
muscular fibre of the uterus, it will be appreciated why such 
growths are much more rare in the ovaries which contain no 
muscular fibres whatever. Dr. Farre discredits the reports of 
large ovarian fibroids which are upon record, and believes them 
to have been in reality either cancerous tumors or growths con- 
nected with the uterus which so encroached upon the ovaries as 
to seem to have sprung from them. When the disease does affect 
the ovary it differs in no essential degree from the same affection 
of the uterus, except that pediculation does not occur as in the 
latter organ, and that the growth of the tumor is much more 
limited. 

The reader must be reminded that these remarks apply to the 
pure fibroid and not the fibro-cystic ovarian tumor, which will 
often attain an immense size, and is always to be regarded as a 
serious disease. They likewise apply to the development of this 
tissue into true fibrous tumors, for in the walls of cystic and cys- 
toid growths fibrous tissue is commonly developed. Yery often 
even a portion of the wall of a simple cyst contains a dense mass 
which is thus composed. 

No medical treatment accomplishes anything in this disease, 
and surgical means are not called for. 

Kiwisch describes enchondromatous and osseous tumors of the 
ovary, but since no other pathologist has met with them, except 
as the latter has been confounded with calcareous degeneration, 
and since Scanzoni has examined the only two cases with which 
Kiwisch ever met, and differs entirely with him as to their cha- 
racter, they may well be left without further mention. As the 
statement made above as to the rarity of fibroids was limited to 
the formation of tumors, so this remark must not be understood 
as applying to cartilaginous and calcareous, commonly called 
osseous, formations in this organ, but only to tumors properly 
so called. Such formations are by no means rare in the walls of 
cysts and intermixed with cancerous growths. 

Cancerous Tumors. — Solid cancerous tumors of the ovary are 



^^M 



COMPOSITE TUMORS OF THE OVARY. 599 

either scirrhus or medullary. The former, in which the fibrous 
element of cancer predominates very largely over the cellular, is 
very rare, and even the latter is by no means common as a pure 
and distinct solid tumor. It generally exists as a composite tumor 
in combination with cystic degeneration. 

When unassociated with cystic degeneration they very rarely 
grow to a large size ; thus scirrhus rarely grows larger than a 
child's head; but when combined with fluid accumulations they 
sometimes attain as extensive dimensions as ordinary cystic disease. 

All cancerous affections of the ovary are likely to be associated 
with the same kind of degeneration in the uterus or some neigh- 
boring part, though in rare cases they are primary. With refer- 
ence to the etiology, course, and prognosis of ovarian cancer there 
is nothing more to be said than that there is no difference between 
them when the affection is ovarian and when it has its seat in 
some other organ of the body. The tendency of the malady is in 
all cases to a rapid, fatal termination, very few cases extending 
beyond a year. The deposit of the cancerous elements is not 
always the same ; at times it is infiltrated throughout the organ, 
whilst at others it is confined in loculi disseminated through it. 

The most frequent complication is peritonitis, and ascites result- 
ing from chronic inflammation of the peritoneum is often present. 

The circumstances which point to the disease are the follow- 
ing :— 

An ovarian tumor of rapid growth ; 

" accompanied by ascites ; 

" " with lancinating pains ; 

" " " chlorosis and oedema pedum ; 

" great constitutional enfeeblement; 
" cachectic appearance. 

In its incipiency the affection is so insidious that either no 
symptoms appear, or they exist to so slight an extent that a diag- 
nosis is often impossible until the disease has advanced. Treat- 
ment, both medical and surgical, is of no avail in these cases. 

COMPOSITE TUMORS OF THE OVARIES. 

This class includes all those tumors which are composed of both 
solid and fluid elements. In some cases where there is a great deal 
of fluid and very little solid, or considerable development of solid 
material and very little fluid, it is difficult to draw the line of dis- 



600 OVARIAN TUMORS. 

tinction, but for clinical purposes the recognition of this as a dis- 
tinct class will prove of signal service. The following are the 
varieties of the affection : — 

Cystic sarcoma ; 

Cystic cancer; 

Alveolar or colloid degeneration. 

Cystic Sarcoma. — In speaking of the pathology of ovarian cysts, 
it was remarked that there exist two theories upon which their 
occurrence was explained, one a dropsy of the Graafian follicles, 
another, the dilatation of the areolae of the stroma and effusion of 
fluid within the spaces thus created. In a manner similar to the 
latter oi these, cysts form likewise in the connective tissue of 
fibrous growths, and the combination of the two elements has 
received the appellation of cystic sarcoma, derived from xvotis, "a 
bladder," and <rapt, "flesh." As the name implies, this form of 
tumor consists of fibrous tissue combined with cysts. Dr. Hewitt 
quotes the report of a microscopical examination made of a speci- 
men shown at the London Pathological Society, as follows: "It 
consists of a delicate, fibrous stroma, forming round, or oval 
alveoli, the latter lined by densely grouped epithelial cells form- 
ing a zone, inclosing an area loosely packed with cellular ele- 
ments of a similar form." 

Kiwisch believes that even in this form of tumor the cystic 
portion may be due to Graafian dropsy, but this view is not shared 
by other pathologists. 

The cysts often grow to a very large size. In Mr. "Wells's ninety- 
first case of ovariotomy the operation was preceded by tapping, 
which removed thirty-eight pints of thin, dark fluid, containing 
much cholesterine. Dr. Fox, who examined the tumor, states that 
the cysts which were emptied by tapping represented one-half the 
bulk of the mass, which even after this weighed thirteen pounds. 
The structure of the solid portion of the tumor was very complex, 
the cysts being of every variety of size and grouped together in 
great confusion. In some the fluid was clear, and in others like 
pea soup. The proportion between the cystic and fibrous elements 
governs the character of these masses to such an extent that it is 
often difficult to classify them. When the former is much in the 
ascendency, the growth resembles a fluid tumor ; when the latter 
predominates, it appears perfectly solid. 



COMPOSITE TUMORS OF THE OVARY. 601 

The contents of the cysts may be colloid, purulent, serous, or 
sanguinolent, and blood is sometimes effused between the fibrous 
interstices so as to cause a rapid increase in size. The cystic sar- 
coma sometimes attains a very large, or, as Kiwisch expresses it, 
" colossal," dimensions. 

In Mr. Wells's case just alluded to the tumor filled the whole 
abdomen, and extended two inches above the ensiform cartilage by 
its upper margin, but its growth was not nearly so rapid as that of 
pure cystic disease. This case had lasted for seven or eight years, 
slowly increasing until 1863, when it developed at the following 
rate ; June to July, one inch, July to August, one inch, August to 
September, one inch, September to October, half an inch, October 
to November, one inch. 

The tendency of these growths is to death, by exhaustion of 
the vital forces, by monorrhagia, or by interference with the func- 
tions of the abdominal viscera. In rare cases, however, a well 
developed tumor may undergo absorption, a fact which I have 
recently had impressed upon me by the following case. 

On the eighth of September, 1866, Dr. Wohlfarth requested 
me to see, in consultation with him, Mrs. W., who had been under 
his care since April of the same year, for a solid tumor of the 
right ovary, which had been rapidly increasing in size. The 
patient was a florid, handsome German woman, of 28 years, and 
married. Upon examination I found a hard, globular tumor, 
larger than the adult head, in the abdomen a little to the left 
side. It was slightly movable, evidently disconnected with the 
uterus, as proved when this organ was moved by the sound, and 
obscurely fluctuating in spots. I diagnosed a cystic sarcoma of 
right ovary. Having an appointment to examine a case in a few 
days with several physicians, I requested Dr. W. to have his 
patient meet me then. Accordingly she was a short time after- 
wards carefully examined by Professors Chas. A. Budd, Foster 
Swift, and Drs. Finnell, Eoth, Wohlfarth, and myself, with the 
unanimous verdict of cystic sarcoma. I am thus particular, 
because I desire to remove all doubt as to the diagnosis. All 
agreed that operative procedure was not indicated or advisable, 
although the patient urgently demanded it. 

In the succeeding month of December, the patient fell while 
walking, and was so much stunned as to be taken up and carried 



602 OVARIAN TUMORS. 

home insensible. A severe and almost fatal attack of peritonitis, 
with a slight attack of pleuro-pneumonia followed, from which 
she recovered in three weeks. Some weeks after this Dr. Wohl- 
farth examined, and was amazed to find that the tumor had dis- 
appeared. I saw her on June 28th, and upon careful examina- 
tion discovered only a tumor at the site of the left ovary, the size 
of a goose's egg. 

This case was fully and minutely examined, was in itself a very 
plain and unmistakable one, and there exists in my mind no doubt 
whatever that the injury done by a violent blow to the tissue of 
the sarcoma caused its removal by absorption. 

Should one or more large cysts be detected, relief to many of 
the symptoms arising from mechanical interference may be ob- 
tained by tapping. The results of the operation are, however, 
more dangerous than in fluid tumors, hemorrhage and subsequent 
inflammation often taking place in consequence of it. Another 
disadvantage attending it is that the operator is more limited as 
to choice of the point to puncture. Besides this means our efforts 
at palliation must consist in relieving symptoms as they occur, 
by giving support to the mass by an abdominal bandage, and by 
enjoining quietude during menstrual epochs. 

The only curative treatment with which we are acquainted 
which avails anything for this form of tumor is removal by ova- 
riotomy. The operation is not so promising as in case of cystic 
degeneration, and should not be undertaken until the evil results 
of the disease and its tendency to destruction of life are fully 
manifested. It requires, generally, the long abdominal incision, 
and is very likely to be accompanied by adhesions ; still, the 
prospect of success is such as to render the operation in many 
cases of grave prognosis not only admissible, but incumbent 
upon us. 

Cystic Cancer. — The formation of fluid collections may occur 
with cancer of the ovary in three ways : 1st, cysts may develop 
in the structure of scirrhus and medullary cancers, as they do in 
that of sarcomata ; 2d, a fluid or cystic tumor, primitively benign, 
may develop malignant material in its cyst wall ; 3d, a large me- 
dullary cancer may, by disintegration at its centre, form within itself 
a mass of fluid, or putrilage, as it has been termed. The condition 
may consist then in cancer complicating cystic degeneration or 



l^BBMHB 



COMPOSITE TUMORS OF THE OVARY. 



603 



in cystic degeneration complicating cancer. According to Scan- 
zoni, the cancerous mass may develop in the tissue of the cyst 
walls and project either internally or externally, or it may grow 
from their walls by pediculated or sessile tumors filled with 
medullary material, which are soft, tumefied, and very vascular. 
In the same tumor both colloid degeneration and medullary cancer 
may be met with. 

The ovarian limits do not always confine these fatal growths. 
At times they surpass them, and affect the peritoneum or other 
neighboring parts. This tendency to eccentric development ac- 
counts for the protuberances, the size of the fist, so often serving 
as means of diagnosis of ovarian cancer. 

The distinguishing characteristic of cystic cancer is its rapidity 
of development. In a few months it often attains a size which 
sarcoma or even cystic degeneration would not attain for several 
years. 

The frequency of these and other ovarian tumors may be 
judged of from reference to some statistics accumulated by Scan- 
zoni and which have been already referred to : — 



Number of cases examined' . 

ovarian tumors among them 
" cases submitted to autopsy 

" fluid tumors . 

" colloid tumors 

" cysto-sarcomata . 

" cvstic cancers 



1823 

97 

41 

25 

9 

5 

2 



From this it will be seen that the affection which we are now 
considering is rarer than sarcoma and very much rarer than 
colloid or alveolar degeneration. 

No treatment, either medical or surgical, holds out any hope of 
cure. If such tumors are removed, their return is inevitable, and 
the operation of ovariotomy is too grave a procedure to be 
adopted merely for the prospect of a few years of life depending 
upon its success. 

The prognosis of this disease is graver and the limit of life 
shorter than in any other affection of the ovaries. 



1 To avoid confusion in the mind of any one examining the original table. 1 would 
remark that Prof. Scanzoni applies the term "composite" not as I do. but as I 
employ " multiple." 



604 OVARIAN TUMORS. 

Alveolar or Colloid Degeneration. — For a longtime the generally 
accepted opinion with reference to colloid (asoxa-a, "glue," and uho^ 
" like") or jelly-like tumors was that they were of cancerous 
nature, but both in their minute structure and in their clinical 
features they are so far removed from true malignant disease that 
the belief is becoming very prevalent that they are not of that 
character. This view is now taken by Drs. Farre, GL Hewitt, 
Kiwisch, Collis, 1 Becquerel, and most of the more recent writers 
upon the subject. In speaking of ovarian colloid tumors Dr. 
Hewitt remarks % " The latter designation (colloid cancer) is not 
a good one, for an attentive consideration of the facts leads to the 
conclusion that the affection is not cancer at all." M. Becquerel 2 
seems to have placed the question in its proper light when he 
says, "Several diseases have been confounded under the indefinite 
name of colloid cysts ; it is therefore essential, before advancing, 
to distinguish these different varieties. We shall now endeavor 
to do this after them (Yirchow and Scanzoni), previously remark- 
ing that under the name of colloid matter some have not at all 
intended to signify a cancerous product, while others have assigned 
it such an origin." Yirchow 3 evidently alludes to this fact when, 
in speaking of the difference between the form and nature of 
growths, he says, " You may therefore say, colloid cancer, colloid 
sarcoma, colloid fibroma. Here colloid means nothing more than 
jelly-like." He then goes on to remark that no confusion should 
exist between such growths as colloid cancer and colloid degene- 
ration of the thyroid gland as to pathological significance. 

Yirchow's description of the condition is thus quoted by 
Becquerel : " Small pouches, which are filled with gelatinous 
matter and whose walls are lined by a layer of epithelium, are 
found in the parenchyma of the ovary. These vesicles develop 
in every direction, but more especially at the periphery of the 
ovaries where they form masses of irregular shape. Some of 
them are isolated, while others are grouped together in the follow- 
ing manner. The walls of these vesicles disappear by atrophy of 
cellular tissue, when they are only formed by their epithelial 
lining. This becomes infiltrated with fat, and the walls forming 
the connection are easily ruptured. Those of the large cyst 

1 Op. cit., p. 205. 2 Op. cit., p. 226. 

3 Cellular Pathol., p. 512. 



COMPOSITE TUMORS OF THE OVARY. 605 

remain intact and become hypertrophied. * * * In other 
cases the vesicles rupture by over-distension ; from this results 
hemorrhage, and blood is found in the vesicles." Kiwisch de- 
scribes it as a breaking up of the stroma of the ovaries into cel- 
lular cavities, alveoli, closely aggregated together and inclosing a 
jelly-like, semifluid mass. By others it has been likened to a 
sponge or a honeycomb. 

It is safe to conclude, from the present aspect of the subject, 
that, while colloid deposit may coexist in the ovary with ence- 
phaloid cancer, the peculiar breaking up of the stroma into alve- 
oli which we have just described, is not a malignant affection, but 
one which seems to constitute a connecting link between cancer 
and the benign degenerations. 

Alveolar degeneration frequently complicates cancer, sarcoma, 
and fluid tumors. " We have observed," says Kiwisch, " alveolar 
degeneration of considerable extent remain in the system for a 
long series of years, without any remarkable bad effects." 
Nevertheless the prognosis of the affection is always grave. 

Should a large cyst be discovered anywhere, and the size of 
the tumor require diminution on account of interference with 
surrounding parts, paracentesis may be practised ; but in a pure 
alveolar tumor, no such accumulation will be discovered. Under 
these circumstances, if the disease steadily advances and the 
constitution suffers in consequence, we should be encouraged by 
recognition of its non-malignant nature to practise ovariotomy. 



CHAPTEE XLV. 

DISEASES OF THE FALLOPIAN TUBES. 

The following diseases of the Fallopian tubes will now be con- 
sidered : — 

Stricture ; 

Displacements ; 

Distension ; 

Inflammation. 
Stricture. — The Fallopian tubes, which are often imperfect or 
wanting when the uterus is in one of these conditions, may, even 
after full development, be affected by stricture. The condition 
may be produced by these causes : — 

Calcific deposit ; 

Senile atrophy ; 

Salpingitis ; 

Pelvic peritonitis ; 

Tubercle or fibrous tumors. 
The obliteration of the canal results in sterility if it affect both 
sides simultaneously, and sometimes, by causing the accumulation 
of fluids, it produces tubal dropsy. It is not rare for rupture of 
the tubes and consequent hematocele and peritonitis to result 
from imprisonment of menstrual fluid in them. M. Puech ana- 
lyzed two hundred and fifty-eight cases of congenital atresia 
of the genital organs, and found that in fifteen cases the Fallo- 
pian tubes were dilated, and in five were ruptured. The condi- 
tion is rather a study for the pathological anatomist than for the 
gynecologist, for it can neither be diagnosticated nor relieved by 
treatment. 

Displacements. — The tubes may pass with hernial contents into 
the inguinal or crural openings, and, in case of inversion of the 
uterus, may descend into the cavity of the displaced organ. It 



DISTENSION. 



607 



is generally in company with the ovary that the tube leaves its 
place, but at times it descends alone. Dr. Scholler 1 reports an 
instance in which, in a child who died twenty days after birth, a 
tumor was discovered which extended from the inguinal region 
to the right labium, and contained the Fallopian tube, which was 
non-adherent. A crural hernia of the tube alone is likewise 
recorded by M. Berard, which ended fatally. 

Prof. Kokitansky, 2 and Dr. Turner, of Scotland, have both re- 
cently drawn attention to severance of the tube from the ovary 
by traction from increased weight of the latter or from false 
membranes. The former produces twelve instances in support 
of the fact. 

Distension. — The tubes may be distended by accumulation of 
mucus, pus, menstrual blood, or a muco-serous material secreted 
by the altered mucous membrane accompanying great and pro- 
longed distension. This condition owns invariably as its moving 
cause, stricture, which prevents the tube from emptying itself into 
the uterus. When very great distension takes place, the accu- 
mulated fluid either forces its way out of the uterine extremity, 
constituting the profluent dropsy of Kokitansky, or passes out of 

Fig. 218. 




Tubal dropsy. (Boivin and Ihiges.) 

the fimbriated extremity into the peritoneum, or a rupture of the 
tube occurs. Such an accumulation may produce a tumor equal 



Courty, op. cit. 



2 Sydenham Soo, Year-Book. 1861 



608 DISEASES OF THE FALLOPIAN TUBES. 

in size to the head of a child of ten years, and some say even 
much larger, though there is doubt as to the authenticity of the 
latter cases. 

Fiff. 219. 




Tubal dropsy. (Simpson.) 

The diagnosis in advanced cases, where, for example, the tumor 
has developed to the extent just mentioned, is difficult and often 
impossible. Sometimes, however, it may be made by the follow- 
ing means; an elongated, fluctuating, movable tumor is felt in 
the retro-uterine space a little to one side ; in its outlines the 
tumor is wavy, and it can be separated from the uterus. Scanzoni 
quotes Kiwisch as declaring that, in these women, the presence 
at the side of the fundus of a mammillated, elastic, and elongated 
tumor, justifies the diagnosis of tubal dropsy, but he differs with 
him, and regards the positive diagnosis as impossible. In case 
the diagnosis can be arrived at, the most appropriate treatment 
will consist in tapping per vaginam. 

Inflammation of the tubes, or salpingitis, consists in inflamma- 
tion of their mucous membrane, and may be either acute or 
chronic. 

The acute variety generally results from puerperal endome- 
tritis, or from gonorrhoea, which has extended through the 
uterine mucous membrane. I have twice seen this disease almost 
destroy life by attacking the uterine mucous membrane, and sub- 
sequently producing pelvic peritonitis, doubtless reaching the 
peritoneum by traversing the tubes. 

Chronic salpingitis is one of the sources of uterine leucorrhcea, 
and often a cause of tubal obstruction and dilatation. 

The great danger of both varieties is pelvic peritonitis, which 



SALPINGITIS. 609 

may spread and destroy life. This arises from emptying of the 
contents of the inflamed tubes into the peritoneum. 

Of the symptoms very little can be said. The chronic variety 
may continue for years, and result in dilatation of the tube with 
no symptoms which arrest attention; while the acute form so 
quickly produces local peritonitis, that its symptoms are lost in 
those of that affection. 

No special treatment is applicable to it except the adoption of 
means to prevent peritonitis, as rest, opiates, leeches, and strict 
avoidance of sexual intercourse. 

The great obscurity of the diagnosis of tubal diseases renders 
the subject one upon which it is not profitable to speak further, 
although as a pathological study it is one of great interest. 

Other Diseases of the Tubes. — In addition to these diseases the 
tubes are sometimes affected by cancer, tubercle, fibrous tumors, 
abscess, and accumulation of blood in their canals from hemor- 
rhage from the mucous membrane. There is so strong an 
analogy between these disorders and the same in other organs, 
that it is not deemed necessary to enter upon their consideration. 



39 



H^M 



INDEX. 



Abdominal supporters, 149 
in chronic corporeal metritis, 258 
Abortion, induction of, in relation to ute- 
rine disease, 58 
Abscess, pelvic, definition of, 380 
pathology of, 380 
causes of, 380 
symptoms of, 380 
physical signs of, 381 
course, duration, and termina- 
tion of, 381 
differentiation of, 381 
prognosis of, 382 
treatment of, 381 
propriety of opening, 383 
time for opening, 384 
point for opening, 384 
methods of evacuating, 384 
means for closure of sac of, 385 
ovarian, 525 

causes of, 526 
symptoms of, 526 
differentiation of, 526 
treatment of, 527 
Air pessary, 36, 149, 297 
Amenorrhcea, definition of, 479 

frequency and varieties of, 479 
pathology of, 479 
influences causing, 480 
causes of, 480 
differentiation of, 482 
treatment of, 483 
cupping the cervix in, 485 
galvanic pessary for, 486 
Anaesthesia in physical diagnosis, 66 
Anteflexion of uterus, definition and fre- 
quency of, 320 
period at which it is most frequent, 

321 
varieties of, 321 
pathology of, 321 
causes of, 322 
symptoms of, 323 
diagnosis of, 323 
prognosis of, 324 
treatment of, 324 

means for preventing recurrence 
of. 324 



Anteflexion of uterus — 

stem-pessaries in treatment of, 325 

means for obviating, 327 

complications of, 327 

operation for, 328 
Anteversion of uterus, definition and fre- 
quency of, 302 

causes of, 303 

influences increasing weight of ute- 
rus, causes of, 303 

symptoms of, 304 

course, duration, and termination 
of, 305 

varieties of, 305 

degrees of, 305 

diagnosis of, 305 

differentiation of, 306 

prognosis of, 306 

treatment of, 306 

means for reduction of, 307 

means for retaining uterus in normal 
position after reduction of, 308 

pessaries in, 309 

elytrorrhaphy in, 309 
Ascent of uterus, 285 
Atresia of vagina, 136 

history, pathology, and varieties 
of, 136 

causes of, 137 

symptoms of, 137 

differentiation of, 138 

treatment of, 139 

different modes of operating for, 140 

period for operating for, 141 
Auscultation, in diagnosis of uterine dis- 
ease, 86 



B 



C 



road ligaments, cysts of, 589 
varieties of, 589 
dropsy of, 590 

Wolffian cysts of, 591 
areolar cysts of, 592 
treatment of, 594 

ancer of uterus, 425 

forms and varieties ot\ 125 
definition and synonymes of, 425 
frequency of, 425 



612 



INDEX, 



Cancer of uterus — 

history of, 426 

differentiation of, 42^ 

pathology of, 427 

tissue first affected, 428 

varieties of, 428 

scirrhus, 428 

causes of, 429 

symptoms of, 429 

physical signs, 430 

ulcerative stage of, 431 

differentiation, 431 

errors in diagnosis of, 432 

extreme degree of ulceration of, 
432 

course and duration of, 432 

complications of, 433 

treatment of, 433 

checking hemorrhage of, 433 

opium in, 434 
epithelial, 438 

varieties of, 438 

differences between epithelial 
and, 438 

ulcerating epithelial, 439 

frequency of, 439 

pathology of, 440 

course and termination of, 441 

symptoms of, 441 

physical signs of, 441 

differentiation of, 442 

treatment of, 442 
Cancroid tumors, of uterus, 435 

varieties of, 435 
Catheter, Sims's, for urinary fistulas, 172 
Cauliflower excrescence of uterus, defini- 
tion and synonymes of, 443 
frequency of, 443 
anatomy of, 444 
pathology of, 444 
site of, 445 
symptoms of, 446 
physical signs of, 447 
differentiation of, 447 
prognosis of, 447 
treatment of, 447 
Cellulitis, peri-uterine, 350 
history of, 350 
definition, synonymes, and frequency 

of, 351 
normal anatomy of, 351 
pathology of, 352 
stages of, 352 
parts affected in, 353 
seat of purulent collection in, 354 
complications of, 355 
course, duration, and termination of, 

355 
course of, after suppuration, 356 
mode of escape of pus in, 356 
prognosis of, 357 



Cellulitis— 

causes of, 357 

symptoms of, 358 

symptoms of chronic, 359 

physical signs of, 359 

differentiation of, 360 

consequences of, 361 

treatment of, 361 

leeches in, 361 

opiates in, 862 

blisters in, 362 

iodide and bromide of potassium in, 

362 
mercurials in, 363 
warm douche in, 363 
Cervix uteri, slitting of, in vesico-uterine 
fistulas, 181 
in relation to vesico-utero-vagi- 

nal fistulas, 182 
dividing line between body and, 

192 
leeches to, in acute metritis, 203 
chronic inflammation of mucous mem- 
brane of, 205 
frequency of, 206 
normal anatomy of mucous mem- 
brane of, 206 
glands of, 207 
rugae of virgin, 208 
villi of, 208 
pathology of chronic endometritis 

of, 209 
causes of chronic endometritis 

of, 209 
symptoms of chronic endome- 
tritis of, 210 
complications of chronic endo- 
metritis of, 210 
physical signs of chronic endo- 
metritis of, 211 
emollient applications in chronic 

endometritis of, 215 
alterative applications in chronic 

endometritis of, 215 
dilatation of, by tent, in chronic 

endometritis of, 215 
cleansing of, in chronic endome- 
tritis of, 215 
importance of cleansing, in chro- 
nic endometritis of, 216 
mode of applying escharotics to, 
in chronic endometritis of, 216 
choice of alterative applications 
in chronic endometritis of, 217 
medicated sponge-tents in treat- 
ment, of chronic endometritis 
of, 221 
resume of plan for applying 
caustics and alteratives to the 
canal of, in chronic endome- 
tritis of, 222 



INDEX, 



613 



Cervix uteri — 

chronic metritis of, 223 
condition of, in, 224 
course and termination of, 224 
pathology of, 224 
differentiation of, 225 
prognosis of, 225 
complications of, 226 
treatment of, 226 
depletion of, in, 227 
scarification of, in, 227 
emollient and sedative applica- 
tions to, in, 228 
vaginal injection to, in, 229 
vaginal suppositories in, 231 
alteratives to, in, 231 
counter-irritation to, in, 233 
mode of blistering the, in, 233 
cauterization of, in, 234 
caustic potash to, in, 235 
method of applying the actual 

cautery to, in, 236 
corporeal endometritis caused by 
inflammation of, 241 
ulceration of, 263 
varieties of, 264 
eversion of, as a cause of, 266 
follicular ulcer of, 271 
operation for eversion of, 269 
inflammatory ulcer of, 272 
syphilitic ulcer of, 273 
corroding ulcer of, 275 
cancerous ulcer of, 276 
division of posterior wall of, for 
relief of anteflexion of uterus, 
329 
polypi of, 421 
epithelioma of, 445 
obstruction or contraction of ca- 
nal of, a cause of dysmenor- 
rhoea, 464 
treatment of constriction of, 466 
Priestly's dilator for, in dysmen- 
orrhea, 468 
incision of, in dysmenorrhcea, 

468 
dry cupping of, in amenorrhoea, 

485 
leucorrhcea of, 489 
abnormal shape of, a cause of 
sterility, 495 
amputation of, 499 
dangers of, 500 
conditions demanding, 500 
varieties of operations for, 501 
method of performing, 501 
by bistoury or scissors, 501 
by ecraseur, 502 
by galvano-caustic, 502 
cases of latter, 504 
Chorion, cystic degeneration of, 452 



Chorion, cystic degeneration of — 
pathology of, 453 
causes of, 453 
symptoms of, 453 
physical signs of, 453 
differentiation of, 454 
prognosis of, 454 
treatment of, 454 
Clitoris, anatomy of, 87 
Coccyx, anatomical relations of, 109 
Coccyodinia, 107 
causes of, 108 
symptoms of, 108 
treatment of, 110 
Conception, prevention of, in relation to 

uterine disease, 58 
Curette, Sims's, for removal of fungous 

growths in uterus, 478 
Cystocele, 146 

as a complication of prolapsus uteri, 
289 
Cysts, ovarian, 528, 529 

pathology of, 529 
varieties of, 530 
unilocular, 530 
multilocular, 531 
multiple, 531 

fluid contained in latter, 532 
size of, 532 
causes of, 532 
symptoms of, 533 
physical signs of, 534 
questions for aid in diagnosti- 
cating, 534 
affections simulating, 536 
differentiation between uterine 

fibroids and, 537 
differentiation between ascitet- 

and, 537 
diagnosis of multilocular, 539 
natural history of, 540 
prognosis of. 541, 
mortality of, 541 
cause of fatal termination of, 512 
treatment of, 543 
tapping of, 544 

mortality after, 544 
advantage of, 545 
indications for, 545 
performed through the abdomi- 
nal walls, 546 
through vaginal walls, 547 
advantages of latter, 547 
mode of performance t! 

vaginal walls, 548 
through rectum, 518 
drainage of, 549 

Kiwisch's method ol\ 
Schuetter's method oi\ 550 
West's method ot\ 550 
trocars for, 551 



614 



I^ T DEX. 



Cysts — 

incision of, 552 
results of, 552 
treatment of sac aft^r, 553 
injection into sac after tapping, 

554 
partial excision of, 556 
methods of latter, 557 
pressure in, 558 
removal of, 560, 572 

tapping after exposing, 575 
Wells's trocar and canula for 

latter, 575 
for securing pedicle of, in, 577 
Wells's clamp for securing pedi- 
cle of, 577 
Storer's, 580 
Wolffian, of broad ligaments, 591 
areolar, of broad ligaments, 592 

Depressor, Sims's, 73 
Diagnosis, means of physical, 66 
vaginal touch in physical, 66 
conj oined manipulation in physical, 67 
abdominal palpation in physical, 69 
rectal touch in physical, 69 
vesico-rectal exploration in physical, 

70 
speculum in physical, 70 
Dilator, Sims's vaginal, in vaginismus, 124 
Displacements, of uterus, 278 
history of, 278 
views of Gynecologists of present 

day in regard to, 279 
definition and synonymes of, 281 
normal anatomy of, 281 
varieties of, 282 
causes of, 283 
influences favorable to, 283 
as a cause of sterility, 495 
Dress, improprieties of, in relation to ute- 
rine disease, 55 
Dropsy, ovarian, 528 

pathology of, 529 

varieties of, 530 

causes of, 532 

symptoms of, 533 

physical signs of, 534 

affections simulating, 536 

differentiation between uterine 

fibroids and, 537 
differentiation between ascites 

and, 537 
prognosis of, 541 
mortality of, 541 
cause of fatality, 542 
treatment of, 543 
tapping in, 544 

mortality after, 544 

indications for, 545 

through abdominal walls, 546 



Dropsy, tapping in — 

trocar for performance of latter 

546 
through vaginal walls, 547 
advantages of latter, 547 
mode of performance through 

vaginal walls, 548 
through rectum, 548 
drainage of cyst in, 549 

Kiwisch'g method of, in, 550 
Schnetter's method of, in, 550 
West's method of, in, 550 
trocars for, 551 
incision of cyst in, 552 

table of results of, 553 
treatment of sac after, 553 
injection into sac after tapping 

in, 554 
tubal, 590 
diagnosis of, 591 
Dysmenorrhoea, definition of, 458 
pathology of, 458 
varieties of, 459 
seat of pain in, 459 
neuralgic, 459 

causes of, 460 
symptoms of, 460 
differentiation of, 460 
prognosis of, 461 
treatment of, 461 
congestive, 462 
causes of, 462 
symptoms of, 462 
differentiation of, 462 
prognosis and treatment of, 462 
inflammatory, 463 
causes of, 463 
symptoms and differentiation of, 

463 
prognosis, 463 
treatment of, 464 
obstructive, 464 

pathology of, 464 
causes of, 464 
symptoms of, 465 
steps of development of, 466 
differentiation of, 466 
prognosis of, 466 
treatment of, when dependent 
on cervical constriction, 
466 
dependent on flexion or ver- 
sion of uterus, 470 
dependent on vaginal stric- 
ture, 471 
dependent on polypus, 
fibroids, or obturator hy- 
men, 471 
membranous, 471 

symptoms of, 472 

prognosis and treatment of, 472 



INDEX, 



615 



Elytrorrhaphy, 297 
Sims's operation of, 298 
Emmet's operation of, 300 
Endometritis, acute, 196 

frequency of, 196 

causes of, 196 

symptoms of, 197 

physical signs of, 198 

pathology of, 198 

course, duration, and termination 
of, 198 

prognosis of, 199 

treatment of, 199 
chronic cervical, 205 

definition of, 205 

pathology of, 209 

causes of, 209 

symptoms of, 210 

complications of, 210 

physical signs of, 211 

differentiation of, 212 

course, duration and termination 
of, 213 

prognosis of, 213 

treatment of, 213 

general regimen in, 214 

emollient applications in, 215 

alterative applications in, 215 

dilatation of cervix by tents in, 
215 

cleansing cervix in, 215 

importance of cleansing cervix 
in, 216 

mode of applying escharotics to 
cervix in, 216 

choice of alterative applications 
in, 217 

medicated sponge tents in, 221 
chronic corporeal, 238 

frequency of, 238 

pathology of, 240 

causes of, 240 

obstruction to escape of men- 
strual blood, as a cause of, 240 

parturient process a frequent 
source of, 241 

inflammation of the cervix some- 
times excites, 241 

sexual intercourse as a cause 
of, 241 

symptoms of, 242 

physical signs of, 244 

pathology of, 245 

prognosis of, 245 

contrast between favorable and 
unfavorable symptoms of, 246 

complications of, 246 

treatment of, 246 

alterative applications in, 247 

methods of cauterizing cavity of 
uterus in, 247 



Endometritis, chronic corporeal — 

caustics which may be employed 
in, 248 

ointments in, 249 

mode of introducing latter, 249 

lunar caustic in, 249 

injections into cavity of uterus 
in, 250 

mode of using latter, 250 

as a cause of sterility, 495 
Endoscope, 85 
Enterocele, 147 

Epithelial cancer of uterus, 438 
Epithelioma of uterus, differences between 
cancer and, 438 

varieties of, 438 
ulcerating, 439 

frequency of, 439 

pathology of, 440 

course, termination, and prog- 
nosis of, 441 

symptoms of, 441 

physical signs of, 441 

differentiation of, 442 

causes of, 442 

treatment of, 442 
vegetating, 443 

definition and synonymes of, 443 

frequency of, 443 

anatomy of, 444 

pathology of, 444 

section of, 445 

site of, 445 

causes of, 446 

symptoms of, 446 

physical signs of, 447 

differentiation of, 447 

prognosis of, 447 

treatment of, 447 
Examination, management of patient dur- 
ing physical, 65 
Exploration, vesico-rectal, in physical 

diagnosis, 70 
Exploring needle, 85 

Fallopian tubes, disease of, 606 
stricture of, 606 
displacements of, 606 
distension of, 607 
other diseases of, 609 
Fibrous tumors, 398. (See Tumors.) 
Fistulse of female genital organs, 151 
varieties of, 151 
urinary, 152 

vesico- vaginal, 152 
urethrovaginal, 152 
vesico-uterine, 152 
vesico-utero-vagiual, 153 
causes of, 153 
symptoms of, 156 
physical signs of, 157 



616 



IXDEX, 



Fistula, urinary — 

complications of, 157 

prognosis of, 157 

history of, 158 

Sims's discoveries in treatment 

of, 161 
Gosset's procedure in the treat- 

of, 161 
Metzler's method in treatment 

of, 162 
means for obtaining a natural 

cure of, 164 
treatment of, 165 
cauterization in, 165 
suture in, 165 
Sims's operation for, 166 
paring edges of, 167 
passing sutures in, 169 
time for removal of sutures in, 
172 
Bozeman's operation for, 174 
Mastin's operation for, 177 
elytroplasty for cure of, 179 
closure of vagina for cure of, 179 
requiring special treatment, 181 
vesico-uterine, 181 
vesico-utero-vaginal, 182 
with extensive destruction of 
base of bladder, 183 
fecal, 184 

varieties of, 184 
causes of, 184 
symptoms of, 185 
physical signs of, 185 
examination for, 185 
prognosis of, 186 
treatment of, 186 
entero-vaginal, 187 
simple vaginal, 187 
peritoneo-vaginal, 188 
perineo- vaginal, 188 
blind vaginal, 188 
Flexions of uterus, 320 
anteflexion, 320 
retroflexion, 330 
lateroflexion, 334 
compound, 334 
frequency of the different varieties 

of, 335 
as a cause of sterility, 495 

Gastrotomy, 413 
propriety of the operation of, 414 
percentage of deaths and recoveries 

in, 415 
causes of fatal termination in, 416 
Genital organs, diagnosis of disease of, 
62 
rational signs of disease of, 63 
fistulee of, 151 
varieties of, 151 



Gland, inflammation of vulvo-vaginal, 94 

anatomy of vulvo-vaginal, 91 

cause of inflammation of vulvo-vagi- 
nal, 94 

symptoms of inflammation of vulvo- 
vaginal, 94 

of the cervix uteri, 207 
Gonorrhoea, 130 

pathology of, 130 

causes of, 131 

symptoms of, 131 

physical signs of, 131 

differentiation of, 132 

complications of, 132 

Hematocele, pudendal, 99 
history of, 99 

pathology of, 100 

causes of, 100 

symptoms of, 101 

differentiation of, 101 

prognosis and treatment of, 101 
pelvic, definition and synonymes of, 
386 

history of, 386 

pathology of, 387 

sources of hemorrhage in, 388 

causes of, 389 

varieties of, 390 

sub-peritoneal, 390 

peritoneal, 390 

symptoms of, 391 

physical signs of, 392 

differentiation of, 393 

course, duration, and termination 
of, 394 

prognosis of, 394 

treatment of, 395 

surgical treatment of, 396 

operation for, 397 

medical treatment of, 397 
Hemorrhage, pudendal, 98 
causes of, 98 
treatment of, 99 
methods of checking, in inversion of 

uterus, 347 
sources of, in pelvic hcematocele, 388 
Hernia, pudendal, 102 

anatomy of, 102 

symptoms of, 102 

treatment of, 103 
vaginal. 142, 146 

vesico, 146 

recto, 147 

entero, 147 

treatment of, 148 
Hydatids of uterus, definition of, 452 
pathology of, 453 
symptoms of, 453 
physical signs of, 453 
differentiation of, 454 



INDEX. 



617 



Hydatids of uterus — 

prognosis of, 454 

treatment of, 454 
Hymen, anatomy of, 88 
Hysterotome, Simpson's, 468 

Stohlnian's, 469 

White's, 470 
Hysterotomy, cervical, for dysmenor- 
rhea, 469 

Inflammation, of vulva, 88 
of vulvo- vaginal gland, 94 
phlegmonous, of labia majora, 96 
of the uterus, 189 

varieties of uterine, 190 
acute, of the mucous membrane of 

cervix uteri, 196 
chronic, of the cervix uteri, 205 
of the cavity of uterus, 238 
of ovaries and uterus a cause of 

peri-uterine cellulitis, 357 
of ovaries, 517 
Inversion of uterus, definition of, 336 
varieties of, 336 
partial and complete, 336 
normal anatomy of, 337 
pathology of, 337 
mechanism of, 337 
causes of, 338 
symptoms of, 341 
physical signs of, 341 
differentiation between polypus and, 

342 
differentiation between fibroid tumors 

and, 342 
course, duration, and termination of, 

342 
prognosis of, 343 
treatment of, 343 
methods of reduction of, 343 
Viardel's method of replacing, 345 
White's method of replacing, 346 
Noeggerath's method of replacing, 

346 
methods of checking hemorrhage in, 

347 
methods of amputating in, 348 
objections to amputation in, 348 

Labia majora, anatomy of, 87 
minora, anatomy of, 87 
phlegmonous inflammation of, 96 
symptoms of phlegmonous inflamma- 
tion of, 96 
treatment of phlegmonous inflamma- 
tion of, 97 
Lateroflexion, 334 

treatment of, 335 
Leucorrhcea, as a symptom of corporeal 
endometritis, 242 
definition of, 487 



Leucorrhcea — 

history of, 487 

pathology of, 488 

varieties of, 488 

microscopical appearance of discharge 

of, 489 
characteristics of discharges of, 489 
causes of, 490 
results of, 491 
treatment of, 491 

Manipulation, conjoined, in physical diag- 
nosis, 67 
practice of conjoined, 68 
Marriage, with existing uterine disease, 

59 
Menorrhagia, definition of, 473 
pathology of, 473 
causes of, 473 
differentiation of, 475 
prognosis of, 476 
results of, 476 
palliative treatment of, 476 
curative treatment of, 477 
empirical treatment of, 478 
Menstruation, imprudence during, in re- 
lation to uterine disease, 57 
sudden suppression of, a cause of 

acute metritis, 201 
disordered, a symptom of corporeal 

endometritis, 242 
imprudence during, a cause of pelvic 

peritonitis, 370 
excessive, 473 
absence of, 479 

excitant of, in amenorrhcea, 486 
Metritis, acute, 200 

frequency of, 200 
causes of, 201 
symptoms of, 202 
physical signs of, 202 
pathology of, 203 
treatment of, 203 
chronic cervical, 223 
causes of, 223 
symptoms of, 223 
physical signs of, 224 
differentiation of, 225 
complications of, 226 
treatment of, 226 
depletion in, 227 
scarification of cervix in, 228 
cupping of cervix in, 22S 
emollient and sedative applica- 
tions in, 228 
vaginal injections in, 229 
vaginal suppositories in, 231 
alteratives in, 231 
why the two latter are beneficial 

in, 282 
counter -irritation in, 2o3 



618 



inde: 



Metritis, chronic cervical— 

mode of blistering; the cervix in. 
233 

cauterizing the cervix in, 234 

caustic potash to the cervix, in, 
235 

method of applying the actual 
cautery to the cervix in, 236 
chronic corporeal, 252 

frequency of, 252 

causes of, 253 

symptoms of, 253 

physical signs of, 254 

pathology of, 254 

differentiation of, 255 

prognosis of, 256 

treatment of, 256 

alteratives in treatment of, 260 

mode of using latter in, 261 

counter-irritation in, 261 

manner of applying latter in, 
261 
Metrorrhagia, definition of, 473 
pathology of, 473 
causes of, 473 
differentiation of, 475 
prognosis of, 476 
results of, 476 
palliative treatment of, 476 
curative treatment of, 477 
empirical treatment of, 478 
Moles of uterus, 449 
definition of, 449 
history of, 450 
pathology of, 450 
causes of, 450 
symptoms of, 451 
physical signs of, 451 
differentiation of, 451 
prognosis and treatment of, 451 



Tervous system, excessive development 
of in relation to uterine disease, 54 



peration, time for, for ruptured peri- 
neum, 114 
Baker Brown's, for ruptured peri- 
neum, 116 
Sims's, for vaginismus, 124 
Emmet's improvement on Sims's, for 

vaginismus, 125 
Burns', for vaginismus, 125 
Simpson's modification of Burns', for 

vaginismus, 126 
Gosset's, for urinary fistulas, 161 
Sims's, for urinary fistulse, 166 
Sims's, for prolapsus uteri, 298 
Emmet's, for prolapsus uteri, 300 
for anteflexion of uterus, 328 
for evacuation of pelvic abscesses, 384 
of hysterotomy, 469 



Operation — ■ 

for amputation of neck of uterus, 

501 
of paracentesis for ovarian dropsv, 

544 
of ovariotomy, 560 
Os uteri, condition of in chronic cervical 
endometritis, 211 
plugging of, in applying leeches to 

the cervix, 227 
plugging of, in applying caustic pot- 
ash to cervix, 235 
obstruction of, a cause of chronic cor- 
poreal endometritis, 240 
dilatation of, a corroborative sign of 
chronic corporeal endometritis, 244 
ulceration of, 263 

situation of, in the first and second 
degrees of prolapsus uteri, 288 
Ovarian apoplexy, definition of, 515 
symptoms of, 516 
prognosis of, 516 
treatment of, 516 
Ovaries, diseases of, 506 
anatomy of, 507 
varieties of diseases of, 508 
imperfect development of, 509 
absence of, 509 
undeveloped, 510 
treatment for latter, 511 
atrophy of, 512 

causes of, 512 

treatment of, 513 

hypertrophy of, 513 

symptoms of, 514 

treatment of, 515 
apoplexy of, 515 

symptoms of, 516 

prognosis of, 516 

treatment of, 516 
dislocation of, 516 

treatment of, 517 
inflammation of, 517 

varieties of, 518 

acute, 518 

chronic, 524 

treatment of, 524, 525 
abscess of, 525 

causes of, 526 

symptoms of, 526 

differentiation of, 526 

treatment of, 527 
tumors of, 528 
hydatid cysts of, 528 

pathology of, 529 

varieties of, 530 

size of, 532 

causes of, 532 

symptoms of, 533 

physical signs of, 534 

affections simulating, 536 



INDEX. 



619 



Ovaries, hydatid cysts of — 

differentiation between uterine 
fibroids and, 537 

differentiation between ascites 
and, 537 

character of, 537 

prognosis of, 541 

mortality of, 541 

causes of fatal termination of, 
542 

treatment of, 543 
tapping, 544 

mortality after, 544 

indications for, 545 

performed through abdominal 
walls, 546 

through vaginal walls, 547 

advantages of latter, 547 

mode of performance through va- 
ginal walls, 548 

through rectum, 548 
drainage of, 549 

Kiwisch's method of, 550 

Schnetter's method of, 550 

West's method of, 550 

trocars for, 551 
incision of, 552 

results of, 552 

treatment of sac after, 553 

injection into sac after tapping, 
'554 

partial excision of, 556 

methods of latter, 557 

removal of, 560 
solid tumors of, 595 

varieties of, 595 
histoid, 595 

size of, 596 

treatment of, 597 
fibrous, 597 

character of, 598 
cancerous, 598 

complications of, 599 
composite tumors of, 599 
cystic sarcoma of, 600 

contents of, 600 

tendency of, 601 
cystic cancer of, 602 

distinguishing characteristic of, 
603 

alveolar or colloid degeneration 
of, 604 
Ovariotomy, 560 

definition of, 560 

history of, 560 

varieties of, 563 

advantages of, 563 

dangers of, 563 

causes of death after performance of, 

563, 564 
statistics of, 565 



Ovariotomy — 

when unadvisable, 567 
conditions favorable to, 567 
preparations for, 570 
treatment of patient before, 571 
operation of, 572 

mode of incising in, 572 

trocar and canula of Wells, for 
tapping cyst in, 575 

removal of sac in, 576 

securing pedicle of cyst in, 577 

Wells's clamp for latter, 577 

obstacles to removal of sac, in, 
581 

closure of wound in, 582 

after treatment of patient in, 584 

causes of death after, 585 

means of avoiding peritonitis 
after, 586 

treatment of septicaemia follow- 
ing, 587 
Ovaritis, 517 

varieties of, 518 
acute, 518 

pathology of, 522 

causes of, 523 

symptoms of, 523 

differentiation of, 523 

prognosis of, 524 

treatment of, 524 
chronic, 524 

symptoms of, 524 

prognosis of, 525 

treatment of, 525 

Palpation, bimanual, in physical ' diag- 
nosis, 67 
abdominal, in physical diagnosis, 69 
abdominal, in diagnosis of pelvic ha> 
matocele, 393 
Paracentesis, for ovarian dropsy, 544 
mortality after, 544 
indications for, 515 
through abdominal walls, 546 
trocar for performance of, 546 
through vaginal walls, 517 
advantages of latter, 547 
mode of performance through vaginal 

walls, 548 
through the rectum, 548 
Parturition, imprudence after, in relation 

to uterine disease, 57 
Pelvis, means for exploring the viscera 
and tissues of, 86 
abscess in, 380 
Percussion, in diagnosis of uterine dis- 
ease, 86 
Peritonitis, pelvic, definition and history 
of, 364 
resemblance to cellulitis, 306 
frequency of. 367 



620 



IXDEX. 



Peritonitis — 

pathology of, 368 

stages of, 368 

causes of, 369 

varieties of, 371 

symptoms of, 371 

physical signs of, 372 

course, duration, and termination of, 

374 
differentiation of, 374 
diagnostic signs between peri-uterine 

cellulitis and, 375 
importance of differentiating, from 

cellulitis, 376 
prognosis of, 376 
results of, 377 
treatment of acute, 377 
treatment of chronic, 377 
evacuation of purulent and serous 

collections, 379 
methods of latter, 379 
Peri-uterine cellulitis, 350. (See Cellu- 
litis.) 
Perineum, rupture of, 111 
normal anatomy of, 111 
results of rupture of, 112 
varieties of rupture of, 113 
prognosis of rupture of, 113 
treatment of rupture of, at time of 

occurrence, 114 
time for operation for rupture of, 

114 
treatment of rupture of, after cica- 
trization, 115 
Baker Brown's operation for rupture 

of, 116 
Sims's operation, 118 
support of in prolapsus uteri, 294 
Pessary, air, first description of, 36 
uses of, in prolapsus uteri, 295 
Coxeter's, 295 
Zwanck's, 295 
Roser's, 296 
Scanzoni's, 296 
Hoffman's, 296 
Bourgeaud's, 297 
Gariel's, 297 

Hodge's closed lever, 317 
Hodge's open lever, 317 
Scattergood's, 317 
Sims's block tin, 318 
Cutter's, 318 
Meigs's, 318 
Peaslee's stem, 326 
Detscky's stem, 326 
Scattergood's, in position, 333 
galvanic, 486 
Polypus, uterine, definition and history 

of, 417 
varieties of, 417 
species of, 418 



Polypus, uterine — 

pathological anatomy of, 419 
cellular, 419 
glandular, 420 
fibrous, 421 
causes of, 422 
symptoms of, 422 
physical signs of, 422 
differentiation of, 423 
course and termination of, 423 
prognosis and complications of, 423 
treatment of, 423 
removal of, 424 
Pregnancy, diseases resulting from, 449 
Probe, uterine, 77 

Sims's smallest, 80 
method of using, 80 
Sims's silver probe for applying caus- 
tics to cervical canal, 218 
Budd's elastic, 219 
Lente's silver caustic, 220 
Procidentia, 287. (See Prolapsus of 

Uterus.) 
Prolapsus, of vagina, 142 
definition of, 142 
pathology of, 144 
causes of, 144 
varieties of, 144 

course, duration, and termina- 
tion, 145 
symptoms of, 145 
treatment of, 148 
surgical procedures for, 149 
of the uterus, 286 
pathology of, 286 
varieties of, 286 
degrees of, 286 
causes of, 287 
course, termination, and duration 

of, 287 
symptoms of, 288 
physical signs of, 288 
differentiation of, 2fc9 
prognosis of, 289 
complications of, 289 
symptoms of sudden, 290 
treatment of, 291 
methods of replacing, 291 
methods of sustaining the uteru3 

in, 291 
means for accomplishing a cure 

of. 292 
recumbent posture in treatment 

of, 293 
astringents and tonics in, 294 
perineal support in, 294 
pessaries in, 295 
Pruritus, of vulva, 103 
causes of, 104 
treatment of, 106 



INDEX, 



621 



Rectocele, 147 
as a complication of prolapsus uteri, 
289 
Retroflexion of uterus, definition and fre- 
quency of, 330 

pathology of, 330 

varieties of, 331 

causes of, 331 

symptoms of, 331 

diagnosis of, 332 

differentiation of, 332 

treatment of, 332 

manner of reduction of, 332 

sustaining of uterus in, 334 

use of pessary in, 334 
Retroversion of uterus, definition and fre- 
quency of, 310 

causes of, 311 

varieties of, 312 

symptoms of, 312 

physical signs of, 313 

degrees of, 313 

differentiation of, 313 

prognosis of, 314 

results of, 314 

treatment of, 314 

means for reduction of, 314 

Sims's repositor for reduction of, 314 

means for retention after reduction 
of, 315 

pessaries in, 317 
Rupture of perineum, 111 

Sound, uterine, first mention of, 35 
Valleix's and Kiwisch's, 77 

method of introducing, 77 

facts ascertained by use of, 78 

Simpson's and Sims's compared, 79 

Sims's smallest, 80 

hard rubber, for dilating the cervix 
in obstructive dysmenorrhoea, 467 
Speculum, first mention of, 34 

ancient, 38 

Sims's, 49, 73 

Fergusson's, 70 

Thomas's telescopic, 71 

Emmet's 74 

Thomas's modification of Sims's, 74 

Cusco's modified, 75 

Sims's with fixed depressor, 75 

method of introducing valvular and 
cylindrical, 75 

introduction of Sims's, and its varie- 
ties, 75 

position for introduction of Sims's, 76 

choice of, in cauterizing cavity of ute- 
rus, 248 
Sterility, as a result and sign of chronic 
corporeal endometritis, 244 

definition of, 493 

history of, 493 



Sterility- 
causes of. 493 

differentiation of, 496 

prognosis of, 496 

treatment of, 497 
Sub- involution of uterus, 454 

pathology of, 455 

symptoms of, 455 

prognosis of 455 

treatment of, 455 
Superinvolution of uterus, 456 

pathology of, 456 

treatment of, 457 
Suppositories, in vaginitis, 135 

in acute endometritis, 199 

in chronic cervical metritis, 231 
Sutures, silver, in operations for ruptured 
perineum, 119 

in treatment of urinary fistulae, 165 

passing, in Sims's operation for cure 
of urinary fistulse, 169 

Tampons, in ulceration of cervix and os 
uteri, 270 
in cancer of uterus, 434 
Tents, sponge, first used by, 81 

object of the use of 81 

mode of preparing, 81 

Nott's manner of preparing, 82 
sea tangle, 83 

preparation of, 83 

mode of introducing, 84 

dangers of, 85 

sponge in chronic cervical endo- 
metritis, 215 

medicated sponge in chronic cer- 
vical endometritis, 221 

medicated sponge, in chronic cor- 
poreal endometritis, 247 

sponge, in neuralgic dysmenor- 
rhoea, 461 
Tumors, fibrous, of uterus, definition and 
synonymes of, 398 

history of, 398 

pathology of, 398 

situation of, 399 

varieties of, 400 

submucous, 400, 406, 413 

subserous, 401 

interstitial, 401 

causes of, 402 

complications of, 402 

symptoms of, 402 

physical signs of, 403 

examination for, 403 

differentiation of, 404 

prognosis of, 404 

frequency of, 404 

course, duration, and termination 
of, 405 

palliative treatment of, 406 



622 



INDEX. 



Tumors, fibrous — 

curative treatment of, 406 

absorption of, 407 

excision of, 407 

Aveling's poly tome for removal 
of, 408 

Nelaton's forceps for removal of, 
408 

ecrasement of, 408 

Emmet's ecraseur, 410 

Gooch's canulse for removal of, 
410 

enucleation of, 411 

sloughing of, 413 

gastrotomy for removal of, 413 

propriety of latter, 414 

percentage of deaths and reco- 
veries in this operation, 415 

causes of fatal termination in 
gastrotomy, 416 
cancroid of uterus, 435 

varieties of, 435 
fibro-plastic of uterus, 435 

pathology of, 435 
recurrent fibroid of uterus, 436 

pathology of, 436 

prognosis in, 437 

frequency of, 437 

fluid, ovarian, 528 

characters of ovarian, 538 
solid ovarian, 595 

varieties of, 595 
composite of ovary, 599 

Ulceration as a cause of fistulse of vagina, 
156 
of os and cervix uteri, 263 
Ulcers of os and cervix uteri, 263 

varieties of, 264 
granular, 264 

causes of, 264 

symptoms of, 265 

physical signs of, 265 

pathology of, 266 

treatment of, 267 

applications to, 268 

tampons in, 270 

caustics in, 271 
follicular, 271 

pathology of, 272 

causes of, 272 

treatment of. 272 
true inflammatory, 272 

prognosis and treatment of, 273 
syphilitic, 273 

frequency of. 273 

course, termination, and differ- 
entiation of, 274 

treatment of, 275 
corroding, 275 
cancerous, 276 



Ulcers, cancerous — 

other varieties of, 277 
corroding of uterus, 439 
frequency of, 439 
pathology of, 440 
symptoms of, 441 
physical signs of. 441 
differentiation of, 442 
treatment of, 442 
Urinary fistulge, 151 

causes of, 153 

symptoms of, 156 

physical signs of, 157 

complications of, 157 

prognosis of, 157 

history of, 158 

Sims's discoveries in treatment 

of, 161 
Gosset's procedure in treatment 

of, 161 
Metzler's method of treatment 

of, 162 
means for obtaining a natural 
cure of, 164 
treatment of, 165 

cauterization in, 165 
suture in, 165 
Sims's operation for, 166 
passing sutures in, 169 
removal of sutures in, 173 
Bozeman's operation for, 174 
requiring special treatment, 118 
Uterus, Bennet's views of disease of, 44 
inflammation of, views of Paulus 

iEgineta, 44 
Tyler Smith's theory of disease of, 

45 
Velpeau's views of disease of, 46 
author's views of disease of, 47 
etiology of disease of, 52 
predisposing causes of disease of, 

53 
improprieties of dress conducive to 

diseases of, 55 
imprudence during menstruation ex- 
citing disease of, 57 
imprudence after parturition causing 

disease of, 57 
rational signs of disease of, 63 
means for physical diagnosis of dis- 
ease of, 66 
method of probing, 80 
means for exploring, 86 
inflammation of, 189 

parts affected in, 189 
varieties of, 190 
prognosis in affections of, 191 
dividing line between the cervix and 

body of, 192 
reasons for frequency of failure in 
treatment of diseases of, 193 



INDEX, 



623 



Uterus — 

imperfect diagnosis of disease of, 

193 
erroneous prognosis of disease of, 

193 
inefficient therapeutics in diseases 

of, 194 
acute inflammation of mucous mem- 
brane of, 196 
chronic inflammation of mucous mem- 
brane of the cervix of, 205 
pathology of, 209 
causes of, 209 
symptoms of, 210 
chronic inflammation of the paren- 
chyma of the cervix of, 223 
pathology of, 224 
treatment of, 226 
counter-irritation to the cervix of, 

233 
mode of blistering the cervix of, 

233 
cauterization of the cervix of, 234 
actual cautery to the cervix of, 

236 
chronic inflammation of the mucous 
membrane of the body of, 238 
frequency of, 238 
pathology of, 240 
causes of, 240 
symptoms of, 242 
treatment of, 246 
cauterization of the cavity of, in, 

247 
caustics which may be employed 

to cauterize cavity of, in, 248 
ointments in, 249 
mode of introducing solid caus- 
tics into cavity of, in, 250 
injections into cavity of, in, 250 
mode of introducing latter, 250 
chronic inflammation of parenchyma 
of, 252 
causes of, 253 
symptoms of, 253 
physical signs of, 254 
pathology of, 254 
differentiation of, 255 
treatment of, 256 
abdominal supporters in, 258 
depletion in, 259 
alterative applications in, 260 
counter-irritation in, 261 
ulcers of the os and cervlfc of, 
263 
displacements of, 278 

normal anatomy of, 281 
varieties of, 282 
causes of, 283 
influences favorable to, 283 
ascent of, 285 



Uterus, ascent of — ■ 

cause of, 285 
descent or prolapsus of, 286 

pathology of, 286 

varieties of, 286 

degrees of, 286 

causes of, 287 

course, duration, and termina- 
tion of, 287 

symptoms of, 288 

physical signs of, 288 

differentiation of, 289 

prognosis of, 289 

complications of, 289 

symptoms of, sudden, 290 

treatment, 291 

methods of replacing, 291 

methods of sustaining, in, 291 

means for accomplishing a cure 
of, 292 

means for diminishing weight of, 
in, 292 

means for strengthening supports 
of, in, 293 

recumbent posture in, 293 

astringents and tonics in, 294 

perineal support in, 294 

pessaries in, 295 
anteversion of, 302 

causes of, 303 

symptoms of, 304 

course, duration, and termina- 
tion of, 305 

varieties of, 305 

diagnosis of, 305 

differentiation of, 306 

prognosis of, 306 

treatment of, 306 

means for reduction of, 307 

means for retaining uterus in 
normal position after reduc- 
tion of, 308 

pessaries in, 309 
retroversion of, 310 

definition and frequency of, 310 

causes of, 311 

varieties of, 312 

symptoms of, 312 

physical signs of, 313 

degrees of, 313 

differentiation of, 313 

prognosis of, 314 

results of, 314 

treatment of, 314 

means for reduction of, 314 

Sims's repositor for reduction of, 
314 

means for retention of uterus in 
place after reduction, 315 

pessaries in, 817 
anteflexion of, 320 



624 



INDEX, 



Uterus, anteflexion of — 

period at which it is most fre- 
quent, 321 

varieties of, 321 

pathology of, 321 

causes of, 322 

symptoms of, 323 

diagnosis of, 323 

prognosis, 324 

treatment of, 324 

means for preventing recurrence 
of, 324 

stem pessaries in treatment of, 
325 

means for obviating consequences 
of, 327 

complications of, 327 

operation for, 328 
retroflexion of, 330 

pathology of, 330 

varieties of, 331 

causes of, 331 

symptoms of, 331 

diagnosis of, 332 

differentiation of, 332 

treatment of, 332 

manner of reduction of, 333 

sustaining of, in, 334 

use of pessary in, 334 
lateroflexion of, 334 

treatment of, 334 
inversion of, 336 

varieties of, 336 

partial, 336 

complete, 336 

normal anatomy of, 337 

pathology of, 33 7 

mechanism of, 337 

causes of, 338 

symptoms of, 341 

physical signs of, 341 

differentiation between polypus 
and, 342 

differentiation between fibroid 
tumors and, 342 

course, duration, and termina- 
tion of, 342 

prognosis of, 343 

treatment of, 343 

methods of reduction of, 343 

Viardel's method of replacing, 
345 

White's method of replacing, 346 

Noeggerath's method of replac- 
ing, 346 

methods of checking hemorrhage 
in, 347 

methods of amputating in, 348 

dangers of amputation in, 348 
fibrous tumors of, 398 
polypi of, 417 



Uterus — 

cancer of, 425 
cancroids of, 435 
fibro-plastic tumors of, 435 
recurrent fibroids of, 436 
epithelioma of, 438 
corroding ulcer of, 439 
moles of, 449 

pathology of, 450 

causes of, 450 

symptoms of, 451 

physical signs of, 451 

differentiation of, 451 

prognosis of, 451 

treatment of, 451 
hydatids of, 452 

definition of, 452 

pathology of, 453 

symptoms of, 453 

physical signs of, 453 

differentiation of, 454 

prognosis of, 454 

treatment of, 454 
subinvolution of, 454 

history of, 454 

pathology of, 455 

causes of, 455 

symptoms of, 455 

prognosis of, 45 5 

treatment of, 455 
superinvolution of, 456 

definition of, 456 

pathology of, 456 

causes of, 456 

symptoms of, 456 

physical signs of, 456 

differentiation of, 456 

results of, 457 

treatment of, 457 

functional disorders of, 458 

flexion of, as a cause of dys- 
menorrhea, 465 

dysmenorrhceal membrane of, 472 

examination of, in menorrhagia 
and metrorrhagia, 475 

treatment of fungous degenera- 
tion of mucous membrane of, 
477 
amputation of neck of, 499 

history of, 499 

dangers of, 500 

conditions demanding, 500 

varieties of operation for, 501 
• methods of performing, 501 

by bistoury or scissors, 501 

by ecraseur, 502 

by galvano-caustic, 502 

Yagina, normal anatomy of, 127 
filiform papilla? of, 127 
epithelium of, in vaginitis, 129 



INDEX. 



625 



Vagina — 

atresia of, 136 

history, pathology, and varieties 

of, 136 
causes of, 137 
symptoms of, 137 
differentiation of, 138 
treatment of, 139 
different modes of operating for, 

140 
period for operating in, 141 
prolapsus of, 142 

definition of, 142 

pathology of, 144 

causes of, 144 

varieties of, 144 

course, duration, and termination 

of, 145 
symptoms of, 145 
treatment of, 148 
complications of, 146 
surgical procedures for, 149 
hernia? of, 146 

fistulae of, 150 

closure of, for cure of urinary 

fistulge, 179 
operation for closure of, 180 
simple fistulse of, 187 
blind fistulae of, 188 
constriction of, for cure of pro- 
lapsus uteri, 297 
stricture of, as a cause of dys- 
menorrhea, 471 
Vaginismus, 121 

anatomy and pathology of, 121 

causes of, 122 

symptoms of, 123 

treatment of, 123 

Sims's vaginal dilator in treatment of, 

124 
Sims's operation for, 124 
Emmet's improvement of Sims's ope- 
ration for, 1 25 
Burns' operation for, 125 
Simpson's modification of Burns' ope- 
ration for, 126 
as a cause of sterility, 494 
Vaginitis, 127 

varieties of, 128 
simple, 128 

causes of, 128 
symptoms of, 129 



Vaginitis, simple — 

physical signs of, 129 

differentiation of, 130 

complications of, 130 
specific, 130 

pathology of, 130 

causes of, 131 

symptoms of, 131 

physical signs of, 131 

differentiation of, 132 

complications of, 132 
granular, 133 

pathology of, 133 

causes of, 134 

symptoms of, 134 

treatment of all varieties of, 
134 
Versions of uterus, 302 
anteversion, 302 
retroversion, 310 
inversion, 336 
as a cause of sterility, 495 
Vestibule, rupture of bulbs of,. 97 
normal anatomy of bulbs of, 97 
plexus of veins of, 98 
Vulva, diseases of, 87 
anatomy of, 87 
inflammation of mucous membrane of, 

88 
varieties of latter, 88 
purulent affection of, 88 
follicular affection of, 90 
gangrenous affection of, 92 
eruptive diseases of, 95 
pruritus of, 103 
treatment of pruritus of, 106 
Vulvitis, 88 

varieties of, 88 

purulent, 88 

causes of purulent, 89 

symptoms of purulent, 

treatment of, 89 

follicular, 90 

causes of follicular, 90 

symptoms of follicular, 

physical signs of follicular, 91 

treatment of follicular, 92 

gangrenous, 92 

causes of gangrenous, 92 

symptoms of gangrenous, 93 

treatment of gangrenous, 93 



89 



91 






THE END. 



40 



3477 

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